Basic Information
| Provider Information | |||||||||
| NPI: | 1023180502 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA HOSPITAL AT MEDICAL CITY DALLAS SUBSIDIARY LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDICAL CITY DALLAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667000 | ||||||||
| FaxNumber: | 9725666248 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667000 | ||||||||
| FaxNumber: | 9725666248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | SHREEVE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9725666225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 121871102 | 05 | TX | MEDICAID |