Provider Demographics
NPI:1255337325
Name:BRENHAM CLINIC ASSN
Entity type:Organization
Organization Name:BRENHAM CLINIC ASSN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATTERY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:979-836-6153
Mailing Address - Street 1:600 NORTH PARK ST
Mailing Address - Street 2:
Mailing Address - City:BRENHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77833-2610
Mailing Address - Country:US
Mailing Address - Phone:979-836-6153
Mailing Address - Fax:
Practice Address - Street 1:600 NORTH PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-836-6153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5283207Q00000X
TXF4241207R00000X
TXH0692207V00000X
TXM4810207V00000X
TXJ6735207X00000X
TXF3730208000000X
TXK6753208000000X
TXE2546208000000X
TXM8802208000000X
TXE87072085R0202X
TXJ1755208600000X
TXG5655208600000X
TXE8650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137248402Medicaid
TX137248402Medicaid
TX00E697Medicare ID - Type UnspecifiedMEDICARE GROUP