Provider Demographics
NPI:1134237266
Name:FOLSOM MEDICAL GROUP
Entity type:Organization
Organization Name:FOLSOM MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BODO
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-832-6545
Mailing Address - Street 1:6510 FOLSOM DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7274
Mailing Address - Country:US
Mailing Address - Phone:409-832-6545
Mailing Address - Fax:409-832-7494
Practice Address - Street 1:6510 FOLSOM DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706
Practice Address - Country:US
Practice Address - Phone:409-832-6545
Practice Address - Fax:409-832-7494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583808363LA2200X, 363LA2200X
TX670528363LA2200X
TXH3231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1154849529OtherNPI
TX1174015184OtherNPI
TX1316478506OtherNPI NUMBER