Provider Demographics
NPI:1588982987
Name:BRAZOSPORT REGIONAL PHYSICIAN SERVICES
Entity type:Organization
Organization Name:BRAZOSPORT REGIONAL PHYSICIAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:JR
Authorized Official - Credentials:FACHE
Authorized Official - Phone:979-285-1105
Mailing Address - Street 1:100 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5674
Mailing Address - Country:US
Mailing Address - Phone:979-297-4411
Mailing Address - Fax:979-285-1730
Practice Address - Street 1:1525 NORTH BROOKS DR
Practice Address - Street 2:
Practice Address - City:BRAZORIA
Practice Address - State:TX
Practice Address - Zip Code:77422
Practice Address - Country:US
Practice Address - Phone:979-798-2747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE COMMUNITY HOSPITAL OF BRAZOSPORT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-10
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty