Basic Information
| Provider Information | |||||||||
| NPI: | 1295736734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTUS HEALTH ARK-LA-TEX | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTUS ST. MICHAEL HEALTH SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848024 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007567999 | ||||||||
| FaxNumber: | 4692821999 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SAINT MICHAEL DR | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755032372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036142019 | ||||||||
| FaxNumber: | 9036142212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | MATTHEW | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7027384546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282N00000X | 000788 | TX | N | Hospitals | General Acute Care Hospital | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 146008105 | 05 | AR | MEDICAID | 770010605 | 01 | AR | BREAST CARE | OTHER | 013954607 | 05 | MO | MEDICAID | 56148 | 05 | TX | MEDICAID | 1733229 | 05 | LA | MEDICAID | 020976901 | 05 | TX | MEDICAID | 094644402 | 05 | TX | MEDICAID | HH0902 | 01 | TX | BLUE CROSS | OTHER | 75503-0000 | 01 | CHAMPUS | OTHER | 00410737X | 05 | GA | MEDICAID | 100703010C | 05 | OK | MEDICAID | 8149704 | 05 | NJ | MEDICAID | 86487 | 01 | LA | BLUE CROSS | OTHER | 10063 | 01 | AR | BLUE CROSS | OTHER |