Basic Information
Provider Information | |||||||||
NPI: | 1073696357 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACKSON COUNTY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JACKSON MEDICAL CLINIC OF GANADO PHYSICIAN GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1013 S WELLS ST | ||||||||
Address2: |   | ||||||||
City: | EDNA | ||||||||
State: | TX | ||||||||
PostalCode: | 779574098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617825241 | ||||||||
FaxNumber: | 3617827495 | ||||||||
Practice Location | |||||||||
Address1: | 202 S. THIRD STREET | ||||||||
Address2: |   | ||||||||
City: | GANADO | ||||||||
State: | TX | ||||||||
PostalCode: | 779621214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3617713571 | ||||||||
FaxNumber: | 3617713574 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HENKE | ||||||||
AuthorizedOfficialFirstName: | MARCELLA | ||||||||
AuthorizedOfficialMiddleName: | VANA | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/CEO | ||||||||
AuthorizedOfficialTelephone: | 3617825241 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208D00000X |   |   | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 85627001 | 05 | TX |   | MEDICAID |