Healthcare Provider Details

I. General information

NPI: 1427183987
Provider Name (Legal Business Name): SOUTH TEXAS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 S LANCASTER RD
DALLAS TX
75216-2532
US

IV. Provider business mailing address

2506 S LANCASTER RD
DALLAS TX
75216-2532
US

V. Phone/Fax

Practice location:
  • Phone: 214-374-2880
  • Fax: 214-374-2853
Mailing address:
  • Phone: 214-374-2880
  • Fax: 214-374-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberJ4593
License Number StateTX

VIII. Authorized Official

Name: DR. JILL WAGGONER
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 214-374-2880