Healthcare Provider Details

I. General information

NPI: 1063699312
Provider Name (Legal Business Name): TEXAS A&M UNIVERSITY SYSTEM HEALTH SCIENCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 E 29TH ST STE 200
BRYAN TX
77802-2623
US

IV. Provider business mailing address

2900 E 29TH ST STE 100
BRYAN TX
77802-2623
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-8440
  • Fax: 877-601-5854
Mailing address:
  • Phone: 979-436-0501
  • Fax: 979-776-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBIN FULLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 979-436-0398