Basic Information
| Provider Information | |||||||||
| NPI: | 1063400778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER-FACILITY-PHYSICIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731912 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753731912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11937 US HIGHWAY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038773451 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | KAVASCH | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9038777399 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 204C00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 127278302 | 05 | TX | MEDICAID |