Provider Demographics
NPI:1184749467
Name:BRETSHIRE MEDICAL CLINIC PA
Entity type:Organization
Organization Name:BRETSHIRE MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LAROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:713-633-2100
Mailing Address - Street 1:7030 BRETSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77016
Mailing Address - Country:US
Mailing Address - Phone:713-633-2100
Mailing Address - Fax:713-633-2103
Practice Address - Street 1:7030 BRETSHIRE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77016
Practice Address - Country:US
Practice Address - Phone:713-633-2100
Practice Address - Fax:713-633-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7432207Q00000X
TXD7470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131844603Medicaid
TXD97474Medicare UPIN
TX00FM78Medicare PIN