Basic Information
| Provider Information | |||||||||
| NPI: | 1184047599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RED RIVER FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX C | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754180180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036407311 | ||||||||
| FaxNumber: | 9036407601 | ||||||||
| Practice Location | |||||||||
| Address1: | 2105 N CENTER ST | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754182627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034494698 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2014 | ||||||||
| LastUpdateDate: | 01/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9036407311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.