Basic Information
| Provider Information | |||||||||
| NPI: | 1497970669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRAZOSPORT RADIOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1547 | ||||||||
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| City: | SEDALIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653021547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6608265960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MEDICAL DR | ||||||||
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| City: | LAKE JACKSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775665674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9792851937 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 06/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | FREEDMAN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9792851937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 196064301 | 05 | TX | MEDICAID | DO3043 | 01 | TX | RR MEDICARE | OTHER |