Provider Demographics
NPI:1912968207
Name:KENNETH JAMES BULEY MD
Entity Type:Organization
Organization Name:KENNETH JAMES BULEY MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BULEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-370-8833
Mailing Address - Street 1:PO BOX 164009
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161
Mailing Address - Country:US
Mailing Address - Phone:817-370-8833
Mailing Address - Fax:817-370-8852
Practice Address - Street 1:6551 HARRIS PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6105
Practice Address - Country:US
Practice Address - Phone:817-370-8833
Practice Address - Fax:817-370-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179438001Medicaid
TX0093DHOtherBCBS