Basic Information
Provider Information
NPI: 1760447163
EntityType: 2
ReplacementNPI:  
OrganizationName: SCOTT & WHITE MEMORIAL HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: BAYLOR SCOTT & WHITE DIALYSIS CENTER - ROUND ROCK
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 847790
Address2:  
City: DALLAS
State: TX
PostalCode: 752847790
CountryCode: US
TelephoneNumber: 2542159522
FaxNumber: 2542159524
Practice Location
Address1: 2120 N MAYS ROCK CREEK PLZ#230
Address2:  
City: ROUND ROCK
State: TX
PostalCode: 786642192
CountryCode: US
TelephoneNumber: 5122382900
FaxNumber: 5122382914
Other Information
ProviderEnumerationDate: 04/19/2006
LastUpdateDate: 01/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MOTAKEF
AuthorizedOfficialFirstName: SHAHIN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 2547246583
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: SCOTT & WHITE MEMORIAL HOSPITAL
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 01/22/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QE0700X007219TXY Ambulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment

ID Information
IDTypeStateIssuerDescription
HH638101TXBLUE CROSSOTHER
1127383-0305TX MEDICAID


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