Provider Demographics
NPI:1578621967
Name:W CHUCK BROGAN III MD PHD PA
Entity Type:Organization
Organization Name:W CHUCK BROGAN III MD PHD PA
Other - Org Name:BROGAN HEART CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:X
Authorized Official - Last Name:KENADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-788-1377
Mailing Address - Street 1:7008 INDIANA AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413
Mailing Address - Country:US
Mailing Address - Phone:806-788-1377
Mailing Address - Fax:806-281-1567
Practice Address - Street 1:7008 INDIANA AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413
Practice Address - Country:US
Practice Address - Phone:806-788-1377
Practice Address - Fax:806-281-1567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9305207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079856301Medicaid
TX00092RMedicare ID - Type Unspecified