Provider Demographics
NPI:1659536944
Name:ETHICUS HOSPITAL DFW LLC
Entity Type:Organization
Organization Name:ETHICUS HOSPITAL DFW LLC
Other - Org Name:SAGECREST HOSPITAL GRAPEVINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-288-1300
Mailing Address - Street 1:4201 WILLIAM D TATE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5736
Mailing Address - Country:US
Mailing Address - Phone:817-288-1300
Mailing Address - Fax:817-288-1499
Practice Address - Street 1:4201 WILLIAM D TATE AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5736
Practice Address - Country:US
Practice Address - Phone:817-288-1300
Practice Address - Fax:817-288-1499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ETHICUS HOSPITAL GRAPEVINE LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-25
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008742282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX452110Medicare Oscar/Certification