Basic Information
| Provider Information | |||||||||
| NPI: | 1992957963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS A&M UNIVERSITY SYSTEM HEALTH SCIENCE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEXAS A&M PHYSICIANS - ROUND ROCK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1114 TAMU COM | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778431114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794360500 | ||||||||
| FaxNumber: | 9797766905 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 N AW GRIMES BLVD | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786653540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9794360500 | ||||||||
| FaxNumber: | 9797766905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9794360500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 200005101 | 05 | TX | MEDICAID |