Basic Information
| Provider Information | |||||||||
| NPI: | 1093868630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UT PHYSICIANS CHOSEN CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301173 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | 720 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257298 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 12/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | CASAS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8323257317 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 181590401 | 05 | TX | MEDICAID |