MEDICARE: TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

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	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CC8142	OTHER	TX	RAILROAD MEDICARE GROUP #

General Provider Information

NPI Number	:	1588622500
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER

Provider Business Mailing Address
First Line	:	PO BOX 9520
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79995-9520
Country	:	US
Telephone Number	:	915-545-6664
Fax Number	:	915-545-9799

Provider Business Practice Location Address
First Line	:	313 S RIO VISTA RD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79927-1646
Country	:	US
Telephone Number	:	915-859-0817
Fax Number	:	915-858-3278

Authorized Official
Title or Position	:	MANAGING DIRECTOR
Name	:	MR. STEVEN M. WAGNER
Credential	:
Telephone Number	:	915-545-6664

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	11/13/2007

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