Basic Information
| Provider Information | |||||||||
| NPI: | 1972519379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAYLOR UNIVERSITY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842022 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752842022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148203151 | ||||||||
| FaxNumber: | 2148208515 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148200111 | ||||||||
| FaxNumber: | 2148204283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | NEWTON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2148203101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LA2100X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 364SM0705X | 000331 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Medical-Surgical | 207QG0300X | 000331 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG5716 | 01 | TX | MCARE RR PROV NUMBER | OTHER |