Provider Demographics
NPI:1205088465
Name:BRAZOS PAIN MANAGEMENT PA
Entity type:Organization
Organization Name:BRAZOS PAIN MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-240-4300
Mailing Address - Street 1:2225 WILLIAMS TRACE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4440
Mailing Address - Country:US
Mailing Address - Phone:281-240-4300
Mailing Address - Fax:281-240-4353
Practice Address - Street 1:2225 WILLIAMS TRACE BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4440
Practice Address - Country:US
Practice Address - Phone:281-240-4300
Practice Address - Fax:281-240-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0837208VP0000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6477860001Medicare PIN
TX0A3205Medicare PIN
TXDO6119Medicare PIN