Basic Information
| Provider Information | |||||||||
| NPI: | 1154547032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STEPHENS MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S GENEVA ST | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764244702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545592241 | ||||||||
| FaxNumber: | 2545596536 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S HARTFORD ST | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764244713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2545592241 | ||||||||
| FaxNumber: | 2545596536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | PARISI | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2545592241 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | HH0092 | 01 | TX | BCBS | OTHER | 119875604 | 05 | TX | MEDICAID |