Provider Demographics
NPI:1942850565
Name:SAM HOUSTON STATE UNIVERSITY
Entity type:Organization
Organization Name:SAM HOUSTON STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO AND SR VP FOR OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITHERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-294-2686
Mailing Address - Street 1:1169 GRAND CENTRAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3185
Mailing Address - Country:US
Mailing Address - Phone:936-525-3600
Mailing Address - Fax:936-525-3624
Practice Address - Street 1:1169 GRAND CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3185
Practice Address - Country:US
Practice Address - Phone:936-525-3600
Practice Address - Fax:936-525-3624
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAM HOUSTON STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-16
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty