MEDICARE: UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS

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	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	149455	OTHER	TX	VENDOR DRUG PROGRAM
2	23929	OTHER	TX	TSBP
3	4589341	OTHER	TX	NCPDP
4	B0138718	OTHER	TX	DPS

General Provider Information

NPI Number	:	1609420025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS

Provider Business Mailing Address
First Line	:	5323 HARRY HINES BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-9922
Country	:	US
Telephone Number	:	469-525-5908
Fax Number	:	214-648-2652

Provider Business Practice Location Address
First Line	:	5303 HARRY HINES BLVD
Second Line	:	SUITE 100 JAMES ASTON AMBULATORY CARE CENTER
City	:	DALLAS
State	:	TX
Zip	:	75390-8862
Country	:	US
Telephone Number	:	214-648-2422
Fax Number	:	214-648-2652

Authorized Official
Title or Position	:	CFO
Name	:	MARK ALAN MEYER
Credential	:
Telephone Number	:	214-633-4804

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	03/07/2023

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