Provider Demographics
NPI:1588030241
Name:TEXAS A&M UNIVERSITY
Entity Type:Organization
Organization Name:TEXAS A&M UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT A.D. ATHLETIC TRAINING
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HEDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, LAT
Authorized Official - Phone:979-862-2930
Mailing Address - Street 1:PO BOX 30017
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77842-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 JOHN DAVID CROW BLVD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77843
Practice Address - Country:US
Practice Address - Phone:979-845-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT56672083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT5667OtherATHLETIC TRAINING