MEDICARE: THE 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1912226572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE UNIVERSITY OF TEXAS SOUTHWESTERN MEDICAL CENTER AT DALLAS

Provider Business Mailing Address
First Line	:	P.O. BOX 845347
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-0624
Fax Number	:	214-645-0078

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD.
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-5347
Country	:	US
Telephone Number	:	214-645-0624
Fax Number	:	214-645-0078

Authorized Official
Title or Position	:	VICE PRESIDENT FOR HEALTH SYSTEM FI
Name	:	BRUCE FAIRBANKS
Credential	:
Telephone Number	:	214-645-0333

Provider Enumeration Date	:	05/21/2010
Last Update Date	:	05/21/2010

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