Basic Information
| Provider Information | |||||||||
| NPI: | 1821397571 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER @ LUBBOCK | ||||||||
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| OtherOrganizationName: | DME - ORTHO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27476 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067434263 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432475 | ||||||||
| FaxNumber: | 8067431290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2011 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | MAGERS | ||||||||
| AuthorizedOfficialFirstName: | BRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8067431830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CD9207 | 01 | TX | RAILROAD MEDICARE | OTHER |