Provider Demographics
NPI:1649234212
Name:UT SOUTHWESTERN DVA HEALTHCARE LLP
Entity Type:Organization
Organization Name:UT SOUTHWESTERN DVA HEALTHCARE LLP
Other - Org Name:UT SOUTHWESTERN OAKCLIFF DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-320-4224
Mailing Address - Fax:800-293-4707
Practice Address - Street 1:655 W ILLINOIS AVE
Practice Address - Street 2:STE 701
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-1814
Practice Address - Country:US
Practice Address - Phone:469-895-5907
Practice Address - Fax:469-895-5931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX006271261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX094313601Medicaid
452773Medicare Oscar/Certification