Provider Demographics
NPI:1912233289
Name:COLLEGE STREET MEDICAL GROUP, P.L.L.C.
Entity Type:Organization
Organization Name:COLLEGE STREET MEDICAL GROUP, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BODRE
Authorized Official - Middle Name:
Authorized Official - Last Name:RISING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-840-9300
Mailing Address - Street 1:5755 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-3518
Mailing Address - Country:US
Mailing Address - Phone:409-840-9300
Mailing Address - Fax:409-842-4960
Practice Address - Street 1:5755 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-3518
Practice Address - Country:US
Practice Address - Phone:409-840-9300
Practice Address - Fax:409-842-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-21
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB107654Medicare PIN
TX6500190001Medicare NSC