Provider Demographics
NPI:1063400778
Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER-FACILITY-PHYSICIAN
Entity type:Organization
Organization Name:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER-FACILITY-PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE/CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-877-7399
Mailing Address - Street 1:PO BOX 731912
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1912
Mailing Address - Country:US
Mailing Address - Phone:903-877-7777
Mailing Address - Fax:
Practice Address - Street 1:11937 US HIGHWAY 271
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-3154
Practice Address - Country:US
Practice Address - Phone:903-877-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127278302Medicaid
TX127278302Medicaid