MEDICARE: BRAZOSPORT PSYCHIATRIC CLINIC

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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1295031979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAZOSPORT PSYCHIATRIC CLINIC

Provider Business Mailing Address
First Line	:	52 FLAG LAKE PLZ
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6263
Country	:	US
Telephone Number	:	713-864-6694
Fax Number	:

Provider Business Practice Location Address
First Line	:	52 FLAG LAKE PLZ
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6263
Country	:	US
Telephone Number	:	713-864-6694
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MATTHEW N BRAMS
Credential	:	MD
Telephone Number	:	713-864-6694

Provider Enumeration Date	:	01/28/2011
Last Update Date	:	01/28/2011

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