Provider Demographics
NPI:1881649747
Name:BRAZOSPORT COMMUNITY MEDICAL CLINIC
Entity Type:Organization
Organization Name:BRAZOSPORT COMMUNITY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PA
Authorized Official - Prefix:MR
Authorized Official - First Name:INYANG
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:979-871-9453
Mailing Address - Street 1:606 N GULF BLVD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:77541-3902
Mailing Address - Country:US
Mailing Address - Phone:979-871-9453
Mailing Address - Fax:979-871-9429
Practice Address - Street 1:606 N GULF BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-3902
Practice Address - Country:US
Practice Address - Phone:979-871-9453
Practice Address - Fax:979-871-9429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00933207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138038816Medicaid
TX162136901Medicaid
TX00869UMedicare PIN
TXP14150Medicare UPIN
TX162136901Medicaid