=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336103902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UT SOUTHWESTERN DVA HEALTHCARE LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2006
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 E AIRPORT FWY
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75062-6305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-438-7375
-----------------------------------------------------
Fax | 972-554-1489
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 VIRGINIA WAY L&C DEPT
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP LICENSURE&CERTIFICATION
-----------------------------------------------------
Name | SAMUEL T WEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-341-6641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 000202
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------