Basic Information
| Provider Information | |||||||||
| NPI: | 1639171093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METROPLEX HEMATOLOGY ONCOLOGY ASSOCIATES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | METROPLEX MEDICAL LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 974315 | ||||||||
| Address2: | METROPLEX MEDICAL LAB | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753974315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172614906 | ||||||||
| FaxNumber: | 8175434675 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 W RANDOL MILL RD | ||||||||
| Address2: | ARLINGTON CANCER CENTER | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760122510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172614906 | ||||||||
| FaxNumber: | 8172615837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICKE | ||||||||
| AuthorizedOfficialFirstName: | KAREL | ||||||||
| AuthorizedOfficialMiddleName: | ADRIAAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8172614906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | METROPLEX HEMATOLOGY ONCOLOGY ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 45D0659783 | 01 | CLIA (CMS) | OTHER | 014329 | 01 | COLA | OTHER | 121904003 | 05 | TX | MEDICAID | 014328 | 01 | COLA | OTHER | 45D0484531 | 01 | CLIA (CMS) | OTHER |