Provider Demographics
NPI:1740022730
Name:KELLCY MEDICAL GROUP
Entity type:Organization
Organization Name:KELLCY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-620-7744
Mailing Address - Street 1:204 CAMP WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-1805
Mailing Address - Country:US
Mailing Address - Phone:830-620-7744
Mailing Address - Fax:830-625-0353
Practice Address - Street 1:204 CAMP WILLOW RD
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-1805
Practice Address - Country:US
Practice Address - Phone:830-620-7744
Practice Address - Fax:830-625-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1881813806OtherGROUP NPI