Provider Demographics
NPI:1912207911
Name:UNIVERSITY OF TEXAS MEDICAL BRANCH
Entity Type:Organization
Organization Name:UNIVERSITY OF TEXAS MEDICAL BRANCH
Other - Org Name:UTMB-CMC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-295-5768
Mailing Address - Street 1:815 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-4729
Mailing Address - Country:US
Mailing Address - Phone:936-295-5768
Mailing Address - Fax:
Practice Address - Street 1:815 11TH ST
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4729
Practice Address - Country:US
Practice Address - Phone:936-295-5768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03334302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization