MEDICARE: BAYLOR COMMUNITY CARE- CITYSQUARE

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	261QP2300X	Primary Care Clinic/Center	07675	TX

General Provider Information

NPI Number	:	1669719282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYLOR COMMUNITY CARE- CITYSQUARE

Provider Business Mailing Address
First Line	:	2835 GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-1647
Country	:	US
Telephone Number	:	214-421-1783
Fax Number	:	214-421-8224

Provider Business Practice Location Address
First Line	:	2835 GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-1647
Country	:	US
Telephone Number	:	214-421-1783
Fax Number	:	214-421-8224

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	LEIGH ALLEN
Credential	:
Telephone Number	:	214-421-1783

Provider Enumeration Date	:	01/16/2013
Last Update Date	:	01/16/2013

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Directions to “BAYLOR COMMUNITY CARE- CITYSQUARE ” Practice Location

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