Provider First Line Business Practice Location Address: 
UT SOUTHWESTERN MEDICAL CENTER 5323 HARRY HINES BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75390-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-645-3979
    Provider Business Practice Location Address Fax Number: 
214-648-7620
    Provider Enumeration Date: 
04/12/2018