Provider Demographics
NPI:1881813806
Name:KELLCY MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:KELLCY MEDICAL GROUP, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANDENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-627-9208
Mailing Address - Street 1:206 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:830-627-9208
Practice Address - Fax:830-625-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5088208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143316101Medicaid
TX143316101Medicaid