Basic Information
Provider Information | |||||||||
NPI: | 1922162890 | ||||||||
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: | 8210 WALNUT HILL LN | ||||||||
Address2: | SUITE 705 | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752314405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143455634 | ||||||||
FaxNumber: | 2143345704 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 11/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRAFT | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | GROUP FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2143455634 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 000431 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 081482401 | 05 | TX |   | MEDICAID |