Basic Information
| Provider Information | |||||||||
| NPI: | 1164443909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
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| OtherOrganizationName: | UTSW MEDICAL CENTER UROLOGICAL SURGERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 7800 PRESTON RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FAIRBANKS | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2146480309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.