Basic Information
| Provider Information | |||||||||
| NPI: | 1083612121 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STONEWALL MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | STONEWALL MEMORIAL HOSPITAL DISTRICT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 N BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | ASPERMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795022029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9409893551 | ||||||||
| FaxNumber: | 9409893662 | ||||||||
| Practice Location | |||||||||
| Address1: | 821 N BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | ASPERMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795022029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9409893551 | ||||||||
| FaxNumber: | 9409893662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | BILLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9409893551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 00G24G | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | D4789 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | J6646 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2084P0800X | H9774 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QC0050X | 453986 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital | 261QR1300X | 453986 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 275N00000X | 000666 | TX | N | Hospital Units | Medicare Defined Swing Bed Unit | 291U00000X | 45D0600750 | TX | N | Laboratories | Clinical Medical Laboratory | 363L00000X | F0906010 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 282NC0060X | 000666 | TX | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 127312001 | 01 | TX | MEDICARE/MEDICAID CROSSOVER | OTHER | 1649378712 | 01 | TX | NP | OTHER | 451318 | 01 | TX | MEDICARE | OTHER | 1972577963 | 01 | TX | PHYSICIAN | OTHER | 0209926-01 | 05 | TX | MEDICAID | 020992601 | 05 | TX | MEDICAID | 096502201 | 05 | TX | MEDICAID | 063461001 | 05 | TX | MEDICAID | 1538142617 | 01 | TX | PHYSICIAN | OTHER |