Provider Demographics
NPI:1972619211
Name:BRAZOSPORT HEALTH ALLIANCE
Entity type:Organization
Organization Name:BRAZOSPORT HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:L L
Authorized Official - Last Name:ZIELECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-299-1210
Mailing Address - Street 1:129 CIRCLE WAY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5249
Mailing Address - Country:US
Mailing Address - Phone:979-299-1210
Mailing Address - Fax:979-299-1136
Practice Address - Street 1:100 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5674
Practice Address - Country:US
Practice Address - Phone:979-299-1210
Practice Address - Fax:979-299-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064NCOtherBLUE CROSS BLUE SHIELD
TX1834285Medicaid
TX1834285Medicaid