Basic Information
Provider Information | |||||||||
NPI: | 1053319798 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BAYLOR SPECIALTY HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OUR CHILDREN'S HOUSE AT BAYLOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 847137 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752847137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2148206710 | ||||||||
FaxNumber: | 2148207950 | ||||||||
Practice Location | |||||||||
Address1: | 3301 SWISS AVE | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752046224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2148209743 | ||||||||
FaxNumber: | 2148201490 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 04/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GALINSKY | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VP, GOVERNMENTAL FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2542159063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 000710 | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 283XC2000X | 000710 | TX | N |   | Hospitals | Rehabilitation Hospital | Children | 282NC2000X | 000710 | TX | Y |   | Hospitals | General Acute Care Hospital | Children |
ID Information
ID | Type | State | Issuer | Description | 094357302 | 05 | TX |   | MEDICAID |