Provider Demographics
NPI:1740495647
Name:TEXAS TECH PHYSICIAN ASSOCIATES AT EL PASO
Entity type:Organization
Organization Name:TEXAS TECH PHYSICIAN ASSOCIATES AT EL PASO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-783-8164
Mailing Address - Street 1:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-781-8164
Mailing Address - Fax:915-783-8187
Practice Address - Street 1:4800 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2709
Practice Address - Country:US
Practice Address - Phone:915-783-8185
Practice Address - Fax:915-783-8187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192487001Medicaid
TXJ77AMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER