Provider Demographics
NPI:1114931391
Name:TEXAS DEPARTMENT OF STATE HEALTH
Entity Type:Organization
Organization Name:TEXAS DEPARTMENT OF STATE HEALTH
Other - Org Name:DEPARTMENT OF STATE HEALTH SERVICES (DSHS) CENTRAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING BRANCH MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:KELLY-KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-776-2589
Mailing Address - Street 1:PO BOX 149347
Mailing Address - Street 2:DSHS- CENTRAL LAB/ZZ320/MC 2004
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78714-9347
Mailing Address - Country:US
Mailing Address - Phone:512-458-7111
Mailing Address - Fax:512-458-7588
Practice Address - Street 1:1100 W 49TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3101
Practice Address - Country:US
Practice Address - Phone:512-458-7111
Practice Address - Fax:512-458-7588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0254062-01Medicaid
TXCL1119OtherMEDICARE PTAN (PROVIDER TRANSACTION ACCESS NUMBER)