MEDICARE: BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	275N00000X	Medicare Defined Swing Bed Hospital Unit

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1Z317	OTHER	AR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1275708885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	201 N CLIFTON ST
Second Line	:
City	:	FORDYCE
State	:	AR
Zip	:	71742-3026
Country	:	US
Telephone Number	:	870-352-6363
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 N CLIFTON ST
Second Line	:
City	:	FORDYCE
State	:	AR
Zip	:	71742-3026
Country	:	US
Telephone Number	:	870-352-6363
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATION / CEO
Name	:	KENNETH E SANDERS
Credential	:
Telephone Number	:	870-352-6363

Provider Enumeration Date	:	04/24/2008
Last Update Date	:	05/18/2017

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