NPIMap

Individual provider Active NPI

Kenya Sekoni Etim, M.D.

  • Adult Medicine Physician
  • Jacksonville, TX
National Provider Identifier
1124061817
Registry record updated Jun 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adult Medicine PhysicianTaxonomy code 207QA0505X
License
T0200 Issued in TX
Practice address
203 Nacogdoches St Ste 280
Jacksonville, TX 75766-2444
Phone
(903) 541-5396
NPI assigned
Jun 13, 2006
Last updated
Jun 23, 2021By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 23, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Adult Medicine Physician 207QA0505X 4301076863 MI
Adult Medicine Physician 207QA0505X T0200 TX Primary

Addresses

Primary practice location

203 Nacogdoches St Ste 280
Jacksonville, TX 75766-2444

Mailing address

203 Nacogdoches St Ste 280
Jacksonville, TX 75766-2444
Phone (903) 541-5396

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210517002693 TX Practitioner - Family Practice 2466445804 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Michigan State University College of Human Medicine, 2000
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Etmc Physician Group, Inc.Group PAC ID 4486915600, 375 clinicians

Practice addresses (Care Compare)

18118 FM 344
Flint, TX 75762-6010
Phone (903) 825-3292

701 Olympic Plaza Cir
Tyler, TX 75701-1950
Phone (903) 531-8109

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Etmc Physician Group Inc. CurrentSince May 1, 2021 Accepting new patients
Etmc Physician Group Inc. CurrentSince May 1, 2021 Accepting new patients
Starks Medical Past Accepting new patients
Jacksonville Hospital LLC Past Accepting new patients

Locations

18118 FM 344 W
Flint, TX 75762
Phone (903) 825-3292

203 Nacogdoches St
Ste 280
Jacksonville, TX 75766
Phone (903) 541-5390

Interoperability endpoints

  • Direct secure messaging: ketim368898@ahs.direct-ci.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150156800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1624406400000",
    "number": "1124061817",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "203 NACOGDOCHES ST STE 280",
            "city": "JACKSONVILLE",
            "state": "TX",
            "postal_code": "757662444",
            "telephone_number": "903-541-5396"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "203 NACOGDOCHES ST STE 280",
            "city": "JACKSONVILLE",
            "state": "TX",
            "postal_code": "757662444",
            "telephone_number": "903-541-5396"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ETIM",
        "first_name": "KENYA",
        "middle_name": "SEKONI",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-06-13",
        "last_updated": "2021-06-23",
        "certification_date": "2021-06-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207QA0505X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adult Medicine",
            "state": "MI",
            "license": "4301076863",
            "primary": false
        },
        {
            "code": "207QA0505X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Adult Medicine",
            "state": "TX",
            "license": "T0200",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, TX

Sources for this page

Verify at the official NPI Registry.