Basic Information
| Provider Information | |||||||||
| NPI: | 1952580433 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UMC PHYSICIAN NETWORK SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY | ||||||||
| Address2: | STE 35 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610334 | ||||||||
| FaxNumber: | 8067222908 | ||||||||
| Practice Location | |||||||||
| Address1: | 4004 82ND ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794231900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067223150 | ||||||||
| FaxNumber: | 8067224674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | AZZINARO | ||||||||
| AuthorizedOfficialFirstName: | JENNETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, CENTRAL BUSINESS OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 8067610334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
| ID | Type | State | Issuer | Description | FTX078 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 147762201 | 05 | TX | MEDICAID |