=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679749659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTT AND WHITE MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 S 31ST ST
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76508-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-724-2111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2317 WARWICKE CT
-----------------------------------------------------
City | TEMPLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76502-7380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-899-0956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPHTHALMOLOGIST
-----------------------------------------------------
Name | DR. J. PAUL DIECKERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 254-724-2111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | M3760
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------