Basic Information
| Provider Information | |||||||||
| NPI: | 1679638126 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEXAS HEALTH PRESBYTERIAN HOSPITAL DALLAS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 E BORDER ST | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760107445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143457260 | ||||||||
| FaxNumber: | 6822364620 | ||||||||
| Practice Location | |||||||||
| Address1: | 8440 WALNUT HILL LN | ||||||||
| Address2: | SUITE 540 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143455634 | ||||||||
| FaxNumber: | 2143457046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAFT | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | GROUP FINANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2143465634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 000431 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 017976401 | 05 | TX | MEDICAID |