Provider Demographics
NPI:1942373816
Name:TEXAS AVENUE MEDICAL CLINIC
Entity Type:Organization
Organization Name:TEXAS AVENUE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-779-4756
Mailing Address - Street 1:1703 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1406
Mailing Address - Country:US
Mailing Address - Phone:979-779-4756
Mailing Address - Fax:979-823-3018
Practice Address - Street 1:1703 E 29TH STREET
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-779-4756
Practice Address - Fax:979-823-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091802101Medicaid
TX0027BMMedicare PIN