1053789370 NPI number — STACEY WELLS MD PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053789370 NPI number — STACEY WELLS MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STACEY WELLS MD PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053789370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
935 ELDRIDGE RD PMB 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77478-2809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-617-0318
Provider Business Mailing Address Fax Number:
833-357-2154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 ST JOSEPH PKWY STE 1400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77002-8237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-617-0318
Provider Business Practice Location Address Fax Number:
833-357-2154
Provider Enumeration Date:
09/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WELLS
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
HOSPITALIST
Authorized Official Telephone Number:
678-427-4494

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  Q2410 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 356086401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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