Provider Demographics
NPI:1962539155
Name:CONROE-WOODLANDS GASTROENTEROLOGY, P.A.
Entity type:Organization
Organization Name:CONROE-WOODLANDS GASTROENTEROLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-760-1900
Mailing Address - Street 1:1020 RIVERWOOD CT STE 300
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2974
Mailing Address - Country:US
Mailing Address - Phone:936-760-1900
Mailing Address - Fax:936-441-1907
Practice Address - Street 1:1020 RIVERWOOD CT STE 300
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2974
Practice Address - Country:US
Practice Address - Phone:936-760-1900
Practice Address - Fax:936-441-1907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1729485Medicaid
TX00897WMedicare ID - Type Unspecified