Basic Information
Provider Information | |||||||||
NPI: | 1043289804 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHRISTUS SPOHN HEALTH SYSTEM CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHRISTUS SPOHN FAMILY HEALTH CENTER FREER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 847899 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752847899 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8007567999 | ||||||||
FaxNumber: | 4692821999 | ||||||||
Practice Location | |||||||||
Address1: | 111 E RILEY ST | ||||||||
Address2: |   | ||||||||
City: | FREER | ||||||||
State: | TX | ||||||||
PostalCode: | 783571830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3613947311 | ||||||||
FaxNumber: | 3613947158 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2006 | ||||||||
LastUpdateDate: | 05/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLOW | ||||||||
AuthorizedOfficialFirstName: | OSBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3612882222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine |   | 261QR1300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 0096HZ | 01 | TX | BLUE CROSS | OTHER | 173157202 | 05 | TX |   | MEDICAID | 173157201 | 05 | TX |   | MEDICAID |