Provider Demographics
NPI:1083703433
Name:UTMB FACULTY GROUP PRACTICE
Entity Type:Organization
Organization Name:UTMB FACULTY GROUP PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIPSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-772-0620
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:ROUTE 1022
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-0848
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:ROUTE 1022
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-0848
Practice Address - Fax:409-772-0885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102673261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00V478B51Medicare ID - Type Unspecified