Provider Demographics
NPI:1578573531
Name:FAMILY PRACTICE FOUNDATION OF THE BRAZOS VALLEY
Entity Type:Organization
Organization Name:FAMILY PRACTICE FOUNDATION OF THE BRAZOS VALLEY
Other - Org Name:FAMILY MEDICINE CENTER & BRAZOS FAMILY MEDICINE RESIDENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-862-4465
Mailing Address - Street 1:1301 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5201
Mailing Address - Country:US
Mailing Address - Phone:979-862-4465
Mailing Address - Fax:979-774-6603
Practice Address - Street 1:1301 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5201
Practice Address - Country:US
Practice Address - Phone:979-862-4465
Practice Address - Fax:979-774-6603
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY PRACTICE FOUNDATION OF THE BRAZOS VALLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111967901Medicaid
TX111967901Medicaid