Provider Demographics
NPI:1407272024
Name:UTMB AT GALVESTON
Entity Type:Organization
Organization Name:UTMB AT GALVESTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:936-258-8013
Mailing Address - Street 1:902 FM 686
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TX
Mailing Address - Zip Code:77535-2299
Mailing Address - Country:US
Mailing Address - Phone:936-258-8013
Mailing Address - Fax:
Practice Address - Street 1:902 FM 686
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TX
Practice Address - Zip Code:77535-2299
Practice Address - Country:US
Practice Address - Phone:936-258-8013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00300302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization