Provider Demographics
NPI:1578788519
Name:BRAZOS WOUND ASSOCIATES, PA
Entity Type:Organization
Organization Name:BRAZOS WOUND ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:M
Authorized Official - Last Name:TADLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-508-1809
Mailing Address - Street 1:PO BOX 4063
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-4063
Mailing Address - Country:US
Mailing Address - Phone:979-764-4325
Mailing Address - Fax:979-764-4345
Practice Address - Street 1:1605 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:979-764-4325
Practice Address - Fax:979-764-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0167208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00671WMedicare PIN