=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245367663
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN MICHAEL KELLY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 RIVER POINTE DR STE 240
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-760-1900
-----------------------------------------------------
Fax | 936-441-1907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 RIVER POINTE DR STE 240
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-2861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-760-1900
-----------------------------------------------------
Fax | 936-441-1907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | F9659
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------