Basic Information
Provider Information | |||||||||
NPI: | 1154378255 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHCA MAINLAND, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MAINLAND MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2756 | ||||||||
Address2: |   | ||||||||
City: | TEXAS CITY | ||||||||
State: | TX | ||||||||
PostalCode: | 775922756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4099385000 | ||||||||
FaxNumber: | 4099385001 | ||||||||
Practice Location | |||||||||
Address1: | 6801 EMMETT F LOWRY EXPY | ||||||||
Address2: |   | ||||||||
City: | TEXAS CITY | ||||||||
State: | TX | ||||||||
PostalCode: | 775912500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4099385000 | ||||||||
FaxNumber: | 4099385001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BENTLEY | ||||||||
AuthorizedOfficialFirstName: | SCOTT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 4099385162 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | HH0115 | 01 | TX | BCBS | OTHER | 520220 | 01 |   | AETNA HMO | OTHER | 565354 | 01 |   | HEALTHLINK | OTHER |