MEDICARE: UTMB REGIONAL MATERNAL AND CHILD HEALTH PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0005X	Ambulatory Family Planning Facility

General Provider Information

NPI Number	:	1013216506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTMB REGIONAL MATERNAL AND CHILD HEALTH PROGRAM

Provider Business Mailing Address
First Line	:	301 UNIVERSITY BLVD.
Second Line	:	ROUTE 1078
City	:	GALVESTON
State	:	TX
Zip	:	77555-1078
Country	:	US
Telephone Number	:	409-772-7725
Fax Number	:	409-772-7726

Provider Business Practice Location Address
First Line	:	3828 HUGHES CT
Second Line	:	104
City	:	DICKINSON
State	:	TX
Zip	:	77539-6235
Country	:	US
Telephone Number	:	281-534-2576
Fax Number	:	281-534-4598

Authorized Official
Title or Position	:	DIRECTOR, CLINICAL SUPPORT SERVICES
Name	:	LIZ CASTILLO
Credential	:
Telephone Number	:	409-772-7725

Provider Enumeration Date	:	03/23/2011
Last Update Date	:	03/23/2011

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