MEDICARE: BASSWOOD MEDICAL CENTER LLC

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	261QE0002X	Emergency Care Clinic/Center	160052	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	434148	OTHER	TX	JACHO

General Provider Information

NPI Number	:	1598014995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BASSWOOD MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 840795
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0795
Country	:	US
Telephone Number	:	972-899-6666
Fax Number	:	972-899-5954

Provider Business Practice Location Address
First Line	:	5401 BASSWOOD BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6909
Country	:	US
Telephone Number	:	972-899-6666
Fax Number	:	972-899-5954

Authorized Official
Title or Position	:	CFO
Name	:	TIM FIELDING
Credential	:
Telephone Number	:	972-899-6650

Provider Enumeration Date	:	08/31/2012
Last Update Date	:	10/21/2013

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