Provider Demographics
NPI:1477091452
Name:UT SOUTHWESTERN
Entity Type:Organization
Organization Name:UT SOUTHWESTERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-648-6410
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-8813
Mailing Address - Country:US
Mailing Address - Phone:210-677-5410
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-8813
Practice Address - Country:US
Practice Address - Phone:210-677-5410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX701376363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1972848760Medicare NSC