Provider Demographics
NPI:1780753624
Name:BRAZOSPORT CARDIOLOGY, P.A.
Entity type:Organization
Organization Name:BRAZOSPORT CARDIOLOGY, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-297-5481
Mailing Address - Street 1:215 OAK DR S STE L
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5618
Mailing Address - Country:US
Mailing Address - Phone:979-297-5481
Mailing Address - Fax:979-297-1924
Practice Address - Street 1:215 OAK DR S STE L
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5618
Practice Address - Country:US
Practice Address - Phone:979-297-5481
Practice Address - Fax:979-297-1924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7694207RC0000X
TXK8835207RC0000X
TXG3437207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L13BOtherPTAN