Provider Demographics
NPI:1861795197
Name:BRAZOSPORT REGIONAL PHYSICIAN SERVICES
Entity type:Organization
Organization Name:BRAZOSPORT REGIONAL PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-285-1105
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5674
Mailing Address - Country:US
Mailing Address - Phone:979-285-1105
Mailing Address - Fax:
Practice Address - Street 1:508 THIS WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5128
Practice Address - Country:US
Practice Address - Phone:979-480-9467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAZOSPORT REGIONAL PHYSICIAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-08
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QU0200X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty