Provider Demographics
NPI:1588622500
Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:TEXAS TECH HEALTH SCIENCES CENTER COMMUNITY CLINICS
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-545-6664
Mailing Address - Street 1:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-6664
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:313 S RIO VISTA RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79927-1646
Practice Address - Country:US
Practice Address - Phone:915-859-0817
Practice Address - Fax:915-858-3278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCC8142OtherRAILROAD MEDICARE GROUP #
TXN18FMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER