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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 
282NC0060X000369TXY HospitalsGeneral Acute Care HospitalCritical Access

ID Information
IDTypeStateIssuerDescription
DF583701TXMEDICARE RAIL ROADOTHER
00X08201TXMEDICARE PART BOTHER
18308610105TX MEDICAID


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