=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538937131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAZOS VALLEY COLORECTAL SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2023
-----------------------------------------------------
Last Update Date | 02/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3201 UNIVERSITY DR E
-----------------------------------------------------
City | BRYAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77802-3475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-315-8121
-----------------------------------------------------
Fax | 855-592-2801
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 FM 594 RD
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77835-5777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-305-9058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | WILLIAM CANNON LEWIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 979-315-8121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208C00000X
-----------------------------------------------------
Taxonomy Name | Colon & Rectal Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------