Healthcare Provider Details

I. General information

NPI: 1457579120
Provider Name (Legal Business Name): BRAZOS LUNG ASSOCIATION, L.L.P.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 E 29TH ST STE 260
BRYAN TX
77802
US

IV. Provider business mailing address

2700 E 29TH ST STE 260
BRYAN TX
77802-2596
US

V. Phone/Fax

Practice location:
  • Phone: 979-774-0012
  • Fax: 979-774-4636
Mailing address:
  • Phone: 979-774-0012
  • Fax: 979-774-4636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: DEBORAH LYNN COLE
Title or Position: BILLING
Credential:
Phone: 979-774-0012