Basic Information
| Provider Information | |||||||||
| NPI: | 1043463433 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRAZOS MEDICAL CLINC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 807 | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766610807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
| FaxNumber: | 2548836835 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 COLEMAN ST | ||||||||
| Address2: | |||||||||
| City: | MARLIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 766612358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548033561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | FEDRO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2548033561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.