Provider Demographics
NPI:1932224821
Name:TEXAS TECH UNIVERSITY HEALTH SCIENCESC CTR.
Entity Type:Organization
Organization Name:TEXAS TECH UNIVERSITY HEALTH SCIENCESC CTR.
Other - Org Name:TEXAS TECH UNIV. HEALTH SCIENCES CTR. PEDIATRICS
Other - Org Type:Other Name
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:915-545-6664
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:915-545-9795
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2702
Practice Address - Country:US
Practice Address - Phone:915-545-9795
Practice Address - Fax:915-545-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX208000000X
2080A0000X, 2080N0001X, 2080P0006X, 2080P0201X, 2080P0202X, 2080P0203X, 2080P0205X, 2080P0208X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
Not Answered2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Not Answered2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty
Not Answered2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
Not Answered2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
Not Answered2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Not Answered2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Multi-Specialty
Not Answered2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP59Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER