Basic Information
| Provider Information | |||||||||
| NPI: | 1639319684 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UT PHYSICIANS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UT PHYSICIANS NEUROSONOLOGY LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 201088 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772161088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6410 FANNIN | ||||||||
| Address2: | 1014 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257080 | ||||||||
| FaxNumber: | 7135122239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2009 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | CASAS | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8323257317 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 293D00000X | Y | Laboratories | Physiological Laboratory |
No ID Information.