Basic Information
| Provider Information | |||||||||
| NPI: | 1063466035 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHCA CLEAR LAKE LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HCA HOUSTON HEALTHCARE CLEAR LAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775984220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813322511 | ||||||||
| FaxNumber: | 2813383352 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775984220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813322511 | ||||||||
| FaxNumber: | 2813383352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2813383110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 121807504 | 05 | TX | MEDICAID | 200360400A | 05 | KS | MEDICAID | XHSP31714 | 05 | CA | MEDICAID | 3810001892 | 05 | WV | MEDICAID | 121807503 | 01 | TX | CSHCN | OTHER | 374024100 | 01 | US DEPT LABOR | OTHER | 564969 | 01 | HEALTHLINK | OTHER | 485113 | 01 | AETNA HMO | OTHER | 1701955 | 05 | LA | MEDICAID | 305252 | 01 | BLACK LUNG | OTHER | HH0667 | 01 | TX | BCBS | OTHER |