Healthcare Provider Details

I. General information

NPI: 1841201092
Provider Name (Legal Business Name): TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER AMARILLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

IV. Provider business mailing address

1400 WALLACE BLVD
AMARILLO TX
79106-1708
US

V. Phone/Fax

Practice location:
  • Phone: 806-354-5688
  • Fax: 806-354-5672
Mailing address:
  • Phone: 806-354-5585
  • Fax: 806-356-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DENISE RUSSELL
Title or Position: CREDENTIALING COORDINATOR
Credential: CPCS
Phone: 806-354-5495