Basic Information
| Provider Information | |||||||||
| NPI: | 1588965131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UT PHYSICIANS - TRAUMA SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 201088 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772161088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
| FaxNumber: | 7135008630 | ||||||||
| Practice Location | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | 1500 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257125 | ||||||||
| FaxNumber: | 7138925500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2010 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | CASAS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8323257317 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0018WN | 01 | TX | BCBSTX | OTHER | 280812302 | 01 | TX | CSHCN | OTHER | 280812301 | 05 | TX | MEDICAID |