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3610 Stagg Dr Beaumont TX 77701-3713 | |
| (409) 673-4139 | |
| (409) 291-8010 |
| Full Name | |
|---|---|
| Speciality | Obstetrics & Gynecology |
| Location | 3610 Stagg Dr, Beaumont, Texas |
| Authorized Official Name and Position | Kimberly Wilson (DIRECTOR) |
| Authorized Official Contact | 4096734139 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 7072 Beaumont TX 77726-7072 Ph: (409) 673-4139 | 3610 Stagg Dr Beaumont TX 77701-3713 Ph: (409) 673-4139 |
| NPI Number | 1720675648 |
|---|---|
| Provider Enumeration Date | 12/26/2020 |
| Last Update Date | 05/10/2021 |
| Certification Date | 05/10/2021 |
| Medicare PECOS PAC ID | 1850705732 |
|---|---|
| Medicare Enrollment ID | O20210204001957 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1720675648 | NPI | - | NPPES |
| 421186401 | Medicaid | TX |
| Provider Name | Sean D Wengroff |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1043273873 PECOS PAC ID: 2860380136 Enrollment ID: I20040308001379 |
| Provider Name | Mary W Martin |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1245244359 PECOS PAC ID: 4183617350 Enrollment ID: I20210303001870 |
| Provider Name | Stevi B Braswell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396334454 PECOS PAC ID: 5092124255 Enrollment ID: I20210429002375 |
| Provider Name | Annette M Brown |
|---|---|
| Provider Type | Practitioner - Obstetrics/gynecology |
| Provider Identifiers | NPI Number: 1891767059 PECOS PAC ID: 0749265700 Enrollment ID: I20210907001137 |
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