Basic Information
| Provider Information | |||||||||
| NPI: | 1689628984 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA HOSPITAL AT MEDICAL CITY DALLAS SUBSIDIARY LP | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | MEDICAL CITY DALLAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667000 | ||||||||
| FaxNumber: | 9725666248 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667000 | ||||||||
| FaxNumber: | 9725666248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHREEVE | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9725666225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000953862X | 05 | GA | MEDICAID | 01401615 | 05 | MS | MEDICAID | 023366800 | 05 | MN | MEDICAID | 100299410A | 05 | KS | MEDICAID | 100697860A | 05 | OK | MEDICAID | 116539105 | 05 | AR | MEDICAID | A5981 | 05 | NM | MEDICAID | 0570044 | 05 | IA | MEDICAID | 119325200 | 05 | WY | MEDICAID | 95015236 | 05 | CO | MEDICAID | 01600873 | 05 | KY | MEDICAID | 166006500 | 01 | DEPT OF LABOR | OTHER | 3018488 | 05 | WA | MEDICAID | 4500647 | 05 | NC | MEDICAID | 016838005 | 05 | MO | MEDICAID | 020943901 | 05 | TX | MEDICAID | 407355 | 05 | AZ | MEDICAID | 6170307 | 05 | NJ | MEDICAID | HH0706 | 01 | TX | BLUE CROSS | OTHER | 100380160A | 05 | IN | MEDICAID | 2458942 | 05 | OH | MEDICAID | 907716200 | 05 | FL | MEDICAID | 01818831 | 05 | NY | MEDICAID | 0450647 | 05 | VT | MEDICAID | 10024974100 | 05 | NE | MEDICAID | 1700622 | 05 | LA | MEDICAID | 0131580 | 05 | SD | MEDICAID | 01614 | 05 | ND | MEDICAID | HOS0647N | 05 | AL | MEDICAID | XHSP33559 | 05 | CA | MEDICAID |