=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902850506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEXAS HEALTH SURGERY CENTER PRESTON PLAZA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 03/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17950 PRESTON RD SUITE 75
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75252-5793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-267-5400
-----------------------------------------------------
Fax | 972-267-0499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17950 PRESTON RD
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75252-5793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-267-5400
-----------------------------------------------------
Fax | 972-267-0499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE VP AND CFO
-----------------------------------------------------
Name | MR. SCOTT T MACOMBER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-780-3234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 008328
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------