Healthcare Provider Details

I. General information

NPI: 1720362502
Provider Name (Legal Business Name): UT SOUTHWESTERN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5303 HARRY HINES BLVD
DALLAS TX
75390-8855
US

IV. Provider business mailing address

5161 HARRY HINES BLVD
DALLAS TX
75235-7707
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-2300
  • Fax: 214-645-2301
Mailing address:
  • Phone: 214-648-7850
  • Fax: 214-648-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number589350
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number589350
License Number StateTX

VIII. Authorized Official

Name: DR. DUKE SAMSON
Title or Position: CHAIRMAN, NEUROSURGERY
Credential: MD
Phone: 214-648-6727