Provider Demographics
NPI:1073592739
Name:UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
Entity Type:Organization
Organization Name:UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CHAIR OF PATHOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:ELGHETANY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-747-2468
Mailing Address - Street 1:3433 COVE VIEW BLVD
Mailing Address - Street 2:APT 3303
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5683
Practice Address - Country:US
Practice Address - Phone:409-772-4866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2002026170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCQP28231OtherLAB DIRECTOR CQ