Provider Demographics
NPI:1023564325
Name:1488 FAMILY MEDICINE GROUP, PLLC
Entity Type:Organization
Organization Name:1488 FAMILY MEDICINE GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER - MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:GUNTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-270-8008
Mailing Address - Street 1:3440 RILEY FUZZELL RD
Mailing Address - Street 2:#120 PMB 29
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-4188
Mailing Address - Country:US
Mailing Address - Phone:936-270-8008
Mailing Address - Fax:936-270-8009
Practice Address - Street 1:2400 FM 1488
Practice Address - Street 2:SUITE 400
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384
Practice Address - Country:US
Practice Address - Phone:936-270-8008
Practice Address - Fax:936-270-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6330261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care