Provider Demographics
NPI:1508053398
Name:UNIVERSITY CANCER CENTER HUNTSVILLE/BRENHAM, INC
Entity Type:Organization
Organization Name:UNIVERSITY CANCER CENTER HUNTSVILLE/BRENHAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-395-0100
Mailing Address - Street 1:PO BOX 5575
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77508-5575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 I 45
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:936-438-8430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5862261QR0200X, 261QX0200X, 261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y285Medicare PIN