Provider Demographics
NPI:1790718419
Name:BRAZOS MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:BRAZOS MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SADTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-764-4043
Mailing Address - Street 1:1602 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8306
Mailing Address - Country:US
Mailing Address - Phone:979-764-4043
Mailing Address - Fax:979-694-2175
Practice Address - Street 1:1602 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 3000
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8306
Practice Address - Country:US
Practice Address - Phone:979-764-4043
Practice Address - Fax:979-694-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9919207Q00000X
TXG0919207Q00000X
TXG1054207V00000X
TXL3243207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084493801Medicaid
TXCH8669OtherMEDICARE RAILROAD
TX00PM97OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX00PM97OtherBLUE CROSS BLUE SHIELD OF TEXAS