Provider Demographics
NPI:1346264538
Name:UNIV PHYS AMARILLO PEDI PARTNERS
Entity Type:Organization
Organization Name:UNIV PHYS AMARILLO PEDI PARTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:806-354-5495
Mailing Address - Street 1:1400 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1786
Mailing Address - Country:US
Mailing Address - Phone:806-354-5630
Mailing Address - Fax:806-354-5689
Practice Address - Street 1:1400 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1708
Practice Address - Country:US
Practice Address - Phone:806-354-5630
Practice Address - Fax:806-354-5689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163173102Medicaid
TX163173103Medicaid
OK200028530 AMedicaid
TX163173105Medicaid
TX163173106Medicaid
NM73623547Medicaid
TX163173101Medicaid
TX163173104Medicaid
TX163173106Medicaid