Provider Demographics
NPI:1508921313
Name:THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Entity Type:Organization
Organization Name:THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS
Other - Org Name:UT SOUTHWESTERN HOME HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT FOR BUSINE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-645-4570
Mailing Address - Street 1:PO BOX 36423
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-9662
Mailing Address - Country:US
Mailing Address - Phone:214-645-4570
Mailing Address - Fax:214-645-4578
Practice Address - Street 1:6333 FOREST PARK ROAD
Practice Address - Street 2:SUITE BLB 304
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9279
Practice Address - Country:US
Practice Address - Phone:214-645-4570
Practice Address - Fax:214-645-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009569251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI175252901Medicaid
TXTPI175252901Medicaid