MEDICARE: PROVIDENT 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	261Q00000X	Clinic/Center	E1172	TX

General Provider Information

NPI Number	:	1659446409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENT MEDICAL CENTER

Provider Business Mailing Address
First Line	:	831 SR L THORNTON FWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75203-2905
Country	:	US
Telephone Number	:	214-948-7783
Fax Number	:	214-948-7793

Provider Business Practice Location Address
First Line	:	831 SR L THORNTON FWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75203-2905
Country	:	US
Telephone Number	:	214-948-7783
Fax Number	:	214-948-7793

Authorized Official
Title or Position	:	OWNER ADMINISTRATOR
Name	:	DR. RONALD JEFFREY WASHINGTON I
Credential	:	M.D
Telephone Number	:	214-948-7783

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	09/06/2023

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Directions to “PROVIDENT MEDICAL CENTER ” Practice Location

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