Provider Demographics
NPI:1336196831
Name:BRAZOS ORTHOPEDIC PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:BRAZOS ORTHOPEDIC PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:979-776-0247
Mailing Address - Street 1:2701 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2504
Mailing Address - Country:US
Mailing Address - Phone:979-776-0247
Mailing Address - Fax:979-774-9515
Practice Address - Street 1:2701 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2504
Practice Address - Country:US
Practice Address - Phone:979-776-0247
Practice Address - Fax:979-774-9515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86496TOtherBLUE CROSS/BLUE SHIELD
TXP49504Medicare UPIN
TX00166SMedicare ID - Type UnspecifiedGROUP