Basic Information
| Provider Information | |||||||||
| NPI: | 1336547587 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STONEWALL MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPUR RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 821 N BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | ASPERMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 795022029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9409893551 | ||||||||
| FaxNumber: | 9409893395 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 E HILL ST | ||||||||
| Address2: | |||||||||
| City: | SPUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 793702532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062713306 | ||||||||
| FaxNumber: | 8702714256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2014 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | KOLB | ||||||||
| AuthorizedOfficialFirstName: | VIRGIL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9409893551 | ||||||||
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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 | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.