Basic Information
| Provider Information | |||||||||
| NPI: | 1144384876 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UT SOUTHWESTERN UNIVERSITY HOSPITAL - ZALE LIPSHY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 849927 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752849927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146454455 | ||||||||
| FaxNumber: | 2146454500 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 HARRY HINES BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753909000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145903172 | ||||||||
| FaxNumber: | 2146454500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT FOR BUSINE | ||||||||
| AuthorizedOfficialTelephone: | 2146483572 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 175289101 | 05 | TX | MEDICAID | 175289103 | 05 | TX | MEDICAID | 022538501 | 05 | TX | MEDICAID | 175289102 | 05 | TX | MEDICAID |