Basic Information
| Provider Information | |||||||||
| NPI: | 1215968748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1204 N MOUND ST | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365644611 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1204 N MOUND ST | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365644611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 08/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRIDGES | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9365688525 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 000478 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 363A00000X | 000478 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 367500000X | 000478 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207P00000X | 000478 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 131030201 | 05 | TX | MEDICAID |