Basic Information
| Provider Information | |||||||||
| NPI: | 1134172406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA MEDICAL CENTER OF ARLINGTON SUBSIDIARY LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL CITY ARLINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 MATLOCK RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760152908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174653241 | ||||||||
| FaxNumber: | 8174724878 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 MATLOCK RD | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760152908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174653241 | ||||||||
| FaxNumber: | 8174724878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ARDEMAGNI | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8174724909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0555599 | 05 | IA | MEDICAID | 100364 | 05 | OR | MEDICAID | XHSP33592 | 05 | CA | MEDICAID | 000953873X | 05 | GA | MEDICAID | 010333100 | 05 | FL | MEDICAID | 0124030 | 05 | SD | MEDICAID | 100504252 | 05 | NV | MEDICAID | 200260770A | 05 | KS | MEDICAID | 401533900 | 05 | MD | MEDICAID | 1001337 | 05 | MA | MEDICAID | 1702340 | 05 | LA | MEDICAID | 37308777 | 05 | CO | MEDICAID | 4500675 | 05 | NC | MEDICAID | HOS0675N | 05 | AL | MEDICAID | 015873904 | 05 | MO | MEDICAID | 203282400 | 01 | DEPT OF LABOR | OTHER | 4506758 | 05 | VA | MEDICAID | 9073906 | 05 | NJ | MEDICAID | 04458031 | 05 | MS | MEDICAID | 100858965000 | 05 | PA | MEDICAID | 104778700 | 05 | MN | MEDICAID | 200041950A | 05 | OK | MEDICAID | 3025210 | 05 | WA | MEDICAID | 0450675 | 05 | TN | MEDICAID | 200373600A | 05 | IN | MEDICAID | 629925 | 05 | AZ | MEDICAID | 807271800 | 05 | ID | MEDICAID | 020950401 | 05 | TX | MEDICAID | 149056105 | 05 | AR | MEDICAID | 21501505 | 05 | NM | MEDICAID | 2483889 | 05 | OH | MEDICAID | HH0579 | 01 | BLUE CROSS | OTHER |