Provider Demographics
NPI:1780628099
Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER
Entity type:Organization
Organization Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT, FINANCE, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-7399
Mailing Address - Street 1:721 CLINIC DR STE B
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2043
Mailing Address - Country:US
Mailing Address - Phone:903-595-7086
Mailing Address - Fax:903-526-3914
Practice Address - Street 1:721 CLINIC DR STE B
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2043
Practice Address - Country:US
Practice Address - Phone:903-595-7086
Practice Address - Fax:903-526-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2098716OtherPK
TX1455591Medicaid
5596640001Medicare NSC