Basic Information
| Provider Information | |||||||||
| NPI: | 1942266333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT & WHITE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYLOR SCOTT & WHITE DIALYSIS CENTER - TEMPLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847790 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542159522 | ||||||||
| FaxNumber: | 2542159524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 THORNTON LN | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765021808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242026 | ||||||||
| FaxNumber: | 2547247012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOTAKEF | ||||||||
| AuthorizedOfficialFirstName: | SHAHIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2547246583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCOTT & WHITE MEMORIAL HOSPITAL | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | 008566 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | HH6140 | 01 | TX | BLUE CROSS | OTHER | 0859936-01 | 05 | TX | MEDICAID |