Provider Demographics
NPI:1962755017
Name:UT SOUTHWESTERN MEDICAL CENTER
Entity type:Organization
Organization Name:UT SOUTHWESTERN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL STAFF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-645-7811
Mailing Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Mailing Address - Street 2:NEUROPSYCHOLOGY 8846, 5323 HARRY HINES BLVD
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UT SOUTHWESTERN MEDICAL CTR
Practice Address - Street 2:NEUROPSYCHOLOGY 8846, 5323 HARRY HINES BLVD
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:214-648-4687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36320261QM0850X
MI6301014547261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health