MEDICARE: BRAZOSPORT PEDIATRIC CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1407860737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZOSPORT PEDIATRIC CLINIC, P.A.

Provider Business Mailing Address
First Line	:	54 FLAG LAKE PLZ
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6263
Country	:	US
Telephone Number	:	979-297-5066
Fax Number	:	979-297-9096

Provider Business Practice Location Address
First Line	:	54 FLAG LAKE PLZ
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6263
Country	:	US
Telephone Number	:	979-297-5066
Fax Number	:	979-297-9096

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD A HARDOIN
Credential	:	M.D.
Telephone Number	:	979-297-5066

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	08/22/2020

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