NPIMap

Organization Active NPI

Dekalb Physicians Clinic LLC

  • Family Medicine Physician
  • De Kalb, TX
National Provider Identifier
1265565691
Registry record updated Jan 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
L5749 Issued in TX
Legal business name
DEKALB PHYSICIANS CLINIC LLC
Practice address
1250 S Runnels St
De Kalb, TX 75559-2317
Phone
(903) 667-2273
Fax
(903) 667-7597
NPI assigned
Mar 14, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 30, 2023

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

Authorized official

Name
Dr. Kyle Wayne Groom, DONPI 1063413656
Title
Owner - Physician
Phone
(903) 667-2273

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X L5749 TX Primary

Addresses

Primary practice location

1250 S Runnels St
De Kalb, TX 75559-2317

Mailing address

216 N Centre St
De Kalb, TX 75559-1406
Phone (903) 667-2273

Other identifiers 3

IdentifierTypeStateIssuer
8S7090OtherTXBLUE CROSS BLUE SHIELD
177214701MedicaidTX
8P152OtherARARK BLUE CROSS BLUE SHIEL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050920000946 TX Part B Supplier - Clinic/Group Practice 0244264216 Receives reassigned benefits from 7 practitioners
Practice locations: Dekalb, TX

National Provider Directory

National Provider Directory

Locations

216 N Centre St
De Kalb, TX 75559
Phone (903) 667-2273

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1173830400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1675036800000",
    "number": "1265565691",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "216 N CENTRE ST",
            "city": "DE KALB",
            "state": "TX",
            "postal_code": "755591406",
            "telephone_number": "903-667-2273",
            "fax_number": "903-667-7597"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1250 S RUNNELS ST",
            "city": "DE KALB",
            "state": "TX",
            "postal_code": "755592317",
            "telephone_number": "903-667-2273",
            "fax_number": "903-667-7597"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEKALB PHYSICIANS CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-14",
        "last_updated": "2023-01-30",
        "certification_date": "2023-01-30",
        "status": "A",
        "authorized_official_last_name": "GROOM",
        "authorized_official_first_name": "KYLE",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "OWNER - PHYSICIAN",
        "authorized_official_telephone_number": "903-667-2273",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "L5749",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "8S7090",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "177214701",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ARK BLUE CROSS BLUE SHIEL",
            "identifier": "8P152",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in De Kalb, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.