Provider Demographics
NPI:1811394208
Name:UTMB
Entity Type:Organization
Organization Name:UTMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:UNIT HEALTH AUTHORTHY
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-454-5036
Mailing Address - Street 1:2350 ATASCOCITA RD
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-3503
Mailing Address - Country:US
Mailing Address - Phone:281-454-5036
Mailing Address - Fax:
Practice Address - Street 1:2350 ATASCOCITA RD
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-3503
Practice Address - Country:US
Practice Address - Phone:281-454-5036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00673305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service