Provider Demographics
NPI:1801817135
Name:BRAZOS VALLEY PHYSICIANS ORGANIZATION,MSO-LLC
Entity Type:Organization
Organization Name:BRAZOS VALLEY PHYSICIANS ORGANIZATION,MSO-LLC
Other - Org Name:THE PHYSICIANS CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:3131 UNIVERSITY DR E
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3473
Mailing Address - Country:US
Mailing Address - Phone:979-731-3250
Mailing Address - Fax:979-731-3957
Practice Address - Street 1:3131 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3473
Practice Address - Country:US
Practice Address - Phone:979-731-3250
Practice Address - Fax:979-731-3957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007175282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094226001Medicaid
TX09422600Medicaid
TX45-0834Medicare ID - Type Unspecified