Basic Information
| Provider Information | |||||||||
| NPI: | 1881654903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METHODIST HOSPTIAL OF DALLAS | ||||||||
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| OtherOrganizationName: | PHYSICIANS EMERGENCY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4040 N CENTRAL EXPY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752043158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145205700 | ||||||||
| FaxNumber: | 2145205794 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 N BECKLEY AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752031201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149478181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | SCHAEFER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXEC VP & CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2149474510 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0064BH | 01 | TX | BLUE CROSS BLUE SHIELD TX | OTHER | 080937801 | 05 | TX | MEDICAID |