Basic Information
| Provider Information | |||||||||
| NPI: | 1134113855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDINA COUNTY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL CLINIC OF HONDO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | HONDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788613534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8304267700 | ||||||||
| FaxNumber: | 8304267860 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | HONDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 788613525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8304267444 | ||||||||
| FaxNumber: | 8304267468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FROSCH | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8304265001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 100046 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 2112245-01 | 05 | TX | MEDICAID | 2326068 | 01 | TX | AETNA PROVIDER # | OTHER | 0080JS | 01 | TX | BLUECROSS PROVIDER # | OTHER | 2112245-02 | 05 | TX | MEDICAID |