Provider Demographics
NPI:1871042754
Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Entity Type:Organization
Organization Name:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-215-4478
Mailing Address - Street 1:4800 ALBERTA AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2709
Mailing Address - Country:US
Mailing Address - Phone:915-215-4478
Mailing Address - Fax:915-545-5755
Practice Address - Street 1:2000 B TRANSMOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79911
Practice Address - Country:US
Practice Address - Phone:915-215-5626
Practice Address - Fax:915-545-6984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty