MEDICARE: BRENHAM CLINIC ASSN

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	G5283	TX
2	207R00000X	Internal Medicine Physician	F4241	TX
3	207V00000X	Obstetrics & Gynecology Physician	H0692	TX
4	207V00000X	Obstetrics & Gynecology Physician	M4810	TX
5	207X00000X	Orthopaedic Surgery Physician	J6735	TX
6	208000000X	Pediatrics Physician	F3730	TX
7	208000000X	Pediatrics Physician	K6753	TX
8	208000000X	Pediatrics Physician	E2546	TX
9	208000000X	Pediatrics Physician	M8802	TX
10	2085R0202X	Diagnostic Radiology Physician	E8707	TX
11	208600000X	Surgery Physician	J1755	TX
12	208600000X	Surgery Physician	G5655	TX
13	207R00000X	Internal Medicine Physician	E8650	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1255337325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENHAM CLINIC ASSN

Provider Business Mailing Address
First Line	:	600 NORTH PARK ST
Second Line	:
City	:	BRENHAM
State	:	TX
Zip	:	77833-2610
Country	:	US
Telephone Number	:	979-836-6153
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 NORTH PARK ST
Second Line	:
City	:	BRENHAM
State	:	TX
Zip	:	77833-2610
Country	:	US
Telephone Number	:	979-836-6153
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. GRACIE SLATTERY
Credential	:	RN
Telephone Number	:	979-836-6153

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	10/19/2009