Basic Information
| Provider Information | |||||||||
| NPI: | 1568961365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO | ||||||||
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| OtherOrganizationName: | UT HEALTH ORTHOPAEDIC - HILL COUNTRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8431 FREDERICKSBURG RD FL 5 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104506810 | ||||||||
| FaxNumber: | 2104506023 | ||||||||
| Practice Location | |||||||||
| Address1: | 25723 OLD FREDERICKSBURG ROAD | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104506810 | ||||||||
| FaxNumber: | 2104506023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2018 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | MARKS | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 2104504621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 407965902 | 01 | TX | CSHCN | OTHER | 407965901 | 05 | TX | MEDICAID |