Basic Information
| Provider Information | |||||||||
| NPI: | 1265646350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARR COUNTY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78 | ||||||||
| Address2: | |||||||||
| City: | RIO GRANDE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785820078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564879025 | ||||||||
| FaxNumber: | 9564874680 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 N FM 3167 | ||||||||
| Address2: | |||||||||
| City: | RIO GRANDE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9564879025 | ||||||||
| FaxNumber: | 9564874680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 04/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | OLIVARES | ||||||||
| AuthorizedOfficialFirstName: | RAFAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9564879025 | ||||||||
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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 | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 136332701 | 05 | TX | MEDICAID | 00FF93 | 01 | TX | BCBS | OTHER | 00C58S | 01 | TX | BCBS | OTHER |