Basic Information
| Provider Information | |||||||||
| NPI: | 1497797005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DALLAS NEPHROLOGY ASSOCIATES VASCULAR CENTER PLANO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DALLAS NEPHROLOGY ASSOCIATES VASCULAR CENTER PLANO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 VICEROY DR | ||||||||
| Address2: | ATT. CREDENTIALING | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752352208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143582300 | ||||||||
| FaxNumber: | 2145796941 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 TRADITION TRL | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750935633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145796600 | ||||||||
| FaxNumber: | 2145796601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | LIANG | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2143582300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DALLAS NEPHROLOGY ASSOCIATES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | LICENSE | 01 | TX | 130356 | OTHER |