Provider Demographics
NPI:1245367663
Name:KELLY, STEPHEN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 RIVER POINTE DR STE 240
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2861
Mailing Address - Country:US
Mailing Address - Phone:936-760-1900
Mailing Address - Fax:936-441-1907
Practice Address - Street 1:1501 RIVER POINTE DR STE 240
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2861
Practice Address - Country:US
Practice Address - Phone:936-760-1900
Practice Address - Fax:936-441-1907
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9659207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1144800Medicaid
TXC17789Medicare UPIN
TX8C0210Medicare ID - Type Unspecified