Healthcare Provider Details

I. General information

NPI: 1609493543
Provider Name (Legal Business Name): BRAZOS VALLEY PHYSICIANS ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 UNIVERSITY DR E STE 100
BRYAN TX
77802-3499
US

IV. Provider business mailing address

3121 UNIVERSITY DR E STE 100
BRYAN TX
77802-3499
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-0169
  • Fax: 979-776-1372
Mailing address:
  • Phone: 979-776-0169
  • Fax: 979-776-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5900