Basic Information
| Provider Information | |||||||||
| NPI: | 1578573531 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY PRACTICE FOUNDATION OF THE BRAZOS VALLEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY MEDICINE CENTER & BRAZOS FAMILY MEDICINE RESIDENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 MEMORIAL DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778025201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798624465 | ||||||||
| FaxNumber: | 9797746603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 MEMORIAL DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778025201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9798624465 | ||||||||
| FaxNumber: | 9797746603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCLELLAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9798624465 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY PRACTICE FOUNDATION OF THE BRAZOS VALLEY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M2390 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 111967901 | 05 | TX | MEDICAID |