Basic Information
| Provider Information | |||||||||
| NPI: | 1427099506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UTMB AUSTIN - INITIATIVES | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 4797-710 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 313 E 12TH ST | ||||||||
| Address2: | STE. 104 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097722222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 09/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4097722222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 174276901 | 05 | TX | MEDICAID |