Provider Demographics
NPI:1811991524
Name:CONROE FAMILY MEDICINE, PA
Entity type:Organization
Organization Name:CONROE FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:PIENIAZEK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:936-756-6661
Mailing Address - Street 1:3205 W DAVIS ST
Mailing Address - Street 2:STE B150
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2066
Mailing Address - Country:US
Mailing Address - Phone:936-756-6661
Mailing Address - Fax:936-756-6681
Practice Address - Street 1:3205 W DAVIS ST
Practice Address - Street 2:STE B150
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2066
Practice Address - Country:US
Practice Address - Phone:936-756-6661
Practice Address - Fax:936-756-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145630301Medicaid
TX00446RMedicare PIN
TX5111940001Medicare NSC