Provider Demographics
NPI:1821054883
Name:UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
Entity Type:Organization
Organization Name:UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON
Other - Org Name:UNIVERSITY OF TEXAS MEDICAL BRANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AD INTERIM
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOUTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-772-1902
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0115
Mailing Address - Country:US
Mailing Address - Phone:409-747-8783
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:RT 1076
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-1388
Practice Address - Country:US
Practice Address - Phone:409-747-6520
Practice Address - Fax:409-747-0164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085973802Medicaid
TX085973802Medicaid