MEDICARE: KENNETH WAYNE HOLLIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	J4856	TX

General Provider Information

NPI Number	:	1689649899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH WAYNE HOLLIS MD

Provider Business Mailing Address
First Line	:	PO BOX 58869
Second Line	:
City	:	WEBSTER
State	:	TX
Zip	:	77598-8869
Country	:	US
Telephone Number	:	281-482-4300
Fax Number	:	281-482-3159

Provider Business Practice Location Address
First Line	:	11914 ASTORIA BLVD STE 125
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-6073
Country	:	US
Telephone Number	:	281-482-4300
Fax Number	:	281-482-3159

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	03/16/2017

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