Provider Demographics
NPI:1851318729
Name:KINGWOOD FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:KINGWOOD FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO, FAAFP
Authorized Official - Phone:281-319-8383
Mailing Address - Street 1:22751 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339
Mailing Address - Country:US
Mailing Address - Phone:281-319-8383
Mailing Address - Fax:281-319-8384
Practice Address - Street 1:22751 PROFESSIONAL DR
Practice Address - Street 2:SUITE 1400
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:281-319-8383
Practice Address - Fax:281-319-8384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF55555261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164252201Medicaid
TXB23117Medicare UPIN
TX00401WMedicare ID - Type Unspecified