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DSH450018AL UNIVERSITY OF TEXAS MEDICAL BRANCH (Terminated)
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Main Details
Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
UTMB TEXAS CITY PEDIATRIC CLINIC
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH450018AL
Medicare Provider Number
450018
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
11/27/2007
Participating Start Date
1/1/2008
Participating Approval Date
12/1/2007
Last Recertification Date
11/27/2017
Termination Date
Termination Reason
4/1/2018
Business decision by the Covered Entity
Contacts
Authorizing Official
UTMB
Carolee A. King, Senior Vice President & General Counsel
(409) 772-1904
Primary Contact
UTMB
Sharon Chapman, Director of Operations
(409) 747-3509
Addresses
Street Address
10121 EMMETT F LOWRY EXPRESSWAY
TEXAS CITY, TX 77591-2286
Billing Address
UTMB
301 UNIVERSITY BLVD
GALVESTON, TX 77555-0510
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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2/7/08 ADDED MED #
02/07/2008
3/23/12 ADDED NPI#; 2/7/08 ADDED MED #
11/27/2007
April 2025
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