=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033310388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF TEXAS MEDICAL BRANCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2007
-----------------------------------------------------
Last Update Date | 08/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 UNIVERSITY BLVD 417 JENNIE SEALY HOSPITAL
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77555-0462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-772-4194
-----------------------------------------------------
Fax | 409-772-9785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 UNIVERSITY BLVD 417 JENNIE SEALY HOSPITAL
-----------------------------------------------------
City | GALVESTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77555-0462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-772-4194
-----------------------------------------------------
Fax | 409-772-9785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER, RESIDENCY TRAINING
-----------------------------------------------------
Name | MS. KIM PANDANELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 409-772-4194
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP0905X
-----------------------------------------------------
Taxonomy Name | State or Local Public Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------