Healthcare Provider Details

I. General information

NPI: 1942373816
Provider Name (Legal Business Name): TEXAS AVENUE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 E 29TH STREET
BRYAN TX
77802
US

IV. Provider business mailing address

1703 E 29TH ST
BRYAN TX
77802-1406
US

V. Phone/Fax

Practice location:
  • Phone: 979-779-4756
  • Fax: 979-823-3018
Mailing address:
  • Phone: 979-779-4756
  • Fax: 979-823-3018

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 Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RANY A CHERIAN
Title or Position: BUSINESS OWNER
Credential: M.D.
Phone: 979-779-4756