Basic Information
Provider Information
NPI: 1073511762
EntityType: 2
ReplacementNPI:  
OrganizationName: BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: BAYLOR SCOTT & WHITE MEDICAL CENTER - GRAPEVINE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 847229
Address2:  
City: DALLAS
State: TX
PostalCode: 752847229
CountryCode: US
TelephoneNumber: 2148203151
FaxNumber: 2148185744
Practice Location
Address1: 1650 W COLLEGE ST
Address2:  
City: GRAPEVINE
State: TX
PostalCode: 760513565
CountryCode: US
TelephoneNumber: 8174811588
FaxNumber: 8173292667
Other Information
ProviderEnumerationDate: 07/07/2005
LastUpdateDate: 04/18/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: YORK
AuthorizedOfficialFirstName: CHRISTOPHER
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 8173292547
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282N00000X000513TXY HospitalsGeneral Acute Care Hospital 

ID Information
IDTypeStateIssuerDescription
12726270305TX MEDICAID


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