Basic Information
| Provider Information | |||||||||
| NPI: | 1275838732 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MULTI SPECIALTY CLINIC IN TARRANT COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 EAST STATE HWY 114 | ||||||||
| Address2: | |||||||||
| City: | SOUTHLAKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760927625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2011 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2146450624 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208800000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 207RN0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.