Provider Demographics
NPI:1457420515
Name:JORGE R BROTHERS M D P A
Entity Type:Organization
Organization Name:JORGE R BROTHERS M D P A
Other - Org Name:ADVANCED UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-771-5882
Mailing Address - Street 1:418 N UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3035
Mailing Address - Country:US
Mailing Address - Phone:806-771-5882
Mailing Address - Fax:806-687-9002
Practice Address - Street 1:418 N UTICA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3035
Practice Address - Country:US
Practice Address - Phone:806-771-5882
Practice Address - Fax:806-687-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1048174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10658823Medicaid
TX0010PCOtherBLUE CROSS BLUE SHOIELD TEXAS
TX186542001Medicaid
TX186542001Medicaid
TX0010PCOtherBLUE CROSS BLUE SHOIELD TEXAS
DF7567Medicare PIN