Healthcare Provider Details

I. General information

NPI: 1942850565
Provider Name (Legal Business Name): SAM HOUSTON STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 GRAND CENTRAL PKWY
CONROE TX
77304-3185
US

IV. Provider business mailing address

1169 GRAND CENTRAL PKWY
CONROE TX
77304-3185
US

V. Phone/Fax

Practice location:
  • Phone: 936-525-3600
  • Fax: 936-525-3624
Mailing address:
  • Phone: 936-525-3600
  • Fax: 936-525-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA WITHERS
Title or Position: CFO AND SR VP FOR OPERATIONS
Credential:
Phone: 936-294-2686