Provider Demographics
NPI:1063461358
Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER LUBBOCK
Entity Type:Organization
Organization Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER LUBBOCK
Other - Org Name:TTUHSC/ANATOMICAL PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-743-1830
Mailing Address - Street 1:PO BOX 27476
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0476
Mailing Address - Country:US
Mailing Address - Phone:806-743-4263
Mailing Address - Fax:806-743-2787
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:STE 1A115
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2155
Practice Address - Fax:806-743-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280869303Medicaid
TX280869301Medicaid
NMG1217Medicaid
TX280869301Medicaid