Provider Demographics
NPI:1235193483
Name:BRYAN FAMILY MEDICINE CLINIC, PA
Entity Type:Organization
Organization Name:BRYAN FAMILY MEDICINE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAILESH
Authorized Official - Middle Name:
Authorized Official - Last Name:DHADUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-776-2200
Mailing Address - Street 1:2709 OSLER BLVD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2518
Mailing Address - Country:US
Mailing Address - Phone:979-776-2200
Mailing Address - Fax:
Practice Address - Street 1:2709 OSLER BLVD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2518
Practice Address - Country:US
Practice Address - Phone:979-776-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0068MYOtherBCBS OF TEXAS
00534ZMedicare ID - Type Unspecified