Basic Information
Provider Information | |||||||||
NPI: | 1306933692 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKDALE BLACKHAWK LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LITTLE RIVER HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1010 | ||||||||
Address2: |   | ||||||||
City: | ROCKDALE | ||||||||
State: | TX | ||||||||
PostalCode: | 765671010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124464500 | ||||||||
FaxNumber: | 5124462063 | ||||||||
Practice Location | |||||||||
Address1: | 1700 BRAZOS AVE | ||||||||
Address2: |   | ||||||||
City: | ROCKDALE | ||||||||
State: | TX | ||||||||
PostalCode: | 765672517 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124464500 | ||||||||
FaxNumber: | 5124462063 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2006 | ||||||||
LastUpdateDate: | 04/02/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MADISON | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5124464500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 282NC0060X | 000369 | TX | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | DF5837 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 00X082 | 01 | TX | MEDICARE PART B | OTHER | 183086101 | 05 | TX |   | MEDICAID |