Provider Demographics
NPI:1114088093
Name:MCBROOM CLINIC PA
Entity Type:Organization
Organization Name:MCBROOM CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEISERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-968-8493
Mailing Address - Street 1:1253 N VON MINDEN ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1262
Mailing Address - Country:US
Mailing Address - Phone:979-968-8493
Mailing Address - Fax:979-968-6388
Practice Address - Street 1:1253 N VON MINDEN ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1262
Practice Address - Country:US
Practice Address - Phone:979-968-8493
Practice Address - Fax:979-968-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207Q00000X
TXL6226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00873ROtherMEDICARE GROUP