Provider Demographics
NPI:1851459457
Name:KELLY W LOBB MD PA
Entity Type:Organization
Organization Name:KELLY W LOBB MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:LOBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-821-7527
Mailing Address - Street 1:1600 JOSEPH DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1502
Mailing Address - Country:US
Mailing Address - Phone:979-821-7527
Mailing Address - Fax:979-821-7528
Practice Address - Street 1:1600 JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1502
Practice Address - Country:US
Practice Address - Phone:979-821-7527
Practice Address - Fax:979-821-7528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8939208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX211321901Medicaid
TXH06261Medicare UPIN
TX211321901Medicaid