Provider Demographics
NPI:1386653277
Name:GULFSIDE MEDICAL CLINIC OF TEXAS, PA
Entity Type:Organization
Organization Name:GULFSIDE MEDICAL CLINIC OF TEXAS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRACKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-729-9811
Mailing Address - Street 1:1209 HIGHWAY 35 N
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-3117
Mailing Address - Country:US
Mailing Address - Phone:361-729-9811
Mailing Address - Fax:361-729-9819
Practice Address - Street 1:1209 HIGHWAY 35 N
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-3117
Practice Address - Country:US
Practice Address - Phone:361-729-9811
Practice Address - Fax:361-729-9819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0025PWOtherBCBS GROUP NUMBER
TX00155UMedicare PIN
TX0025PWOtherBCBS GROUP NUMBER