Basic Information
Provider Information | |||||||||
NPI: | 1780183590 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UT HEALTH ORTHOPAEDIC - MARC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8431 FREDERICKSBURG RD FL 5 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293392 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104509300 | ||||||||
FaxNumber: | 2104506023 | ||||||||
Practice Location | |||||||||
Address1: | 8300 FLOYD CURL DR FL 3 | ||||||||
Address2: |   | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782293931 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2104509300 | ||||||||
FaxNumber: | 2104506023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2018 | ||||||||
LastUpdateDate: | 06/23/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARKS | ||||||||
AuthorizedOfficialFirstName: | ANDREA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP & CFO | ||||||||
AuthorizedOfficialTelephone: | 2104504621 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 406402401 | 05 | TX |   | MEDICAID | 406402402 | 01 | TX | CSHCN | OTHER |