Basic Information
Provider Information | |||||||||
NPI: | 1508916826 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCOTT & WHITE MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAYLOR SCOTT & WHITE DIALYSIS CENTER - KILLEEN WEST | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2201 S W S YOUNG DR STE 101B | ||||||||
Address2: |   | ||||||||
City: | KILLEEN | ||||||||
State: | TX | ||||||||
PostalCode: | 765435316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2545506466 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2201 S W S YOUNG DR STE 101B | ||||||||
Address2: |   | ||||||||
City: | KILLEEN | ||||||||
State: | TX | ||||||||
PostalCode: | 765435316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2545016467 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2007 | ||||||||
LastUpdateDate: | 01/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOTAKEF | ||||||||
AuthorizedOfficialFirstName: | SHAHIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2547246583 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.