Provider Demographics
NPI:1679574750
Name:BRAZOS UROLOGY CLINIC P A
Entity type:Organization
Organization Name:BRAZOS UROLOGY CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-573-3272
Mailing Address - Street 1:1209 MEDICAL PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5684
Mailing Address - Country:US
Mailing Address - Phone:817-573-3272
Mailing Address - Fax:817-573-4626
Practice Address - Street 1:1209 MEDICAL PLAZA CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5684
Practice Address - Country:US
Practice Address - Phone:817-573-3272
Practice Address - Fax:817-573-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7993208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166393201Medicaid
TX166393201Medicaid