MEDICARE: BRAZOSPORT EAR, NOSE & THROAT CLINIC, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	F1152	TX

General Provider Information

NPI Number	:	1013998673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZOSPORT EAR, NOSE & THROAT CLINIC, PA

Provider Business Mailing Address
First Line	:	201 OAK DR S
Second Line	:	SUITE 207
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5676
Country	:	US
Telephone Number	:	979-297-2477
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 OAK DR S
Second Line	:	SUITE 207
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5676
Country	:	US
Telephone Number	:	979-297-2477
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRUCE PAUL MEYERS
Credential	:	MD
Telephone Number	:	979-297-2477

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	08/22/2020

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