Healthcare Provider Details

I. General information

NPI: 1124791744
Provider Name (Legal Business Name): PBH PROFESSIONAL GROUP, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 NORMAND DR STE 100
COLLEGE STATION TX
77845-6399
US

IV. Provider business mailing address

103 POWELL CT STE 100
BRENTWOOD TN
37027-5050
US

V. Phone/Fax

Practice location:
  • Phone: 979-218-5916
  • Fax: 979-401-4170
Mailing address:
  • Phone: 615-308-7871
  • Fax: 615-261-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: FLORA SADRI-AZARBAYEJANI
Title or Position: PRESIDENT AND SECRETARY
Credential: D.O.
Phone: 413-522-9246