Provider Demographics
NPI:1821039058
Name:UTMB FACULTY GROUP PRACTICE
Entity Type:Organization
Organization Name:UTMB FACULTY GROUP PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-772-2222
Mailing Address - Street 1:P O BOX 4797-710
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4797
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:950 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705-2251
Practice Address - Country:US
Practice Address - Phone:409-833-3826
Practice Address - Fax:409-833-9575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112048704Medicaid
TX112048704Medicaid