Provider Demographics
NPI:1043463433
Name:BRAZOS MEDICAL CLINC PA
Entity type:Organization
Organization Name:BRAZOS MEDICAL CLINC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:FEDRO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-803-3561
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:MARLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76661-0807
Mailing Address - Country:US
Mailing Address - Phone:254-803-3561
Mailing Address - Fax:254-883-6835
Practice Address - Street 1:322 COLEMAN ST
Practice Address - Street 2:
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661-2358
Practice Address - Country:US
Practice Address - Phone:254-803-3561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J4549Medicare PIN
TXD97329Medicare UPIN