Basic Information
| Provider Information | |||||||||
| NPI: | 1366532228 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN SPECIALTY HOSPITAL KINGWOOD L L C | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORIAL HERMANN SURGICAL HOSPITAL KINGWOOD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 DALLAS PKWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752542916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727633859 | ||||||||
| FaxNumber: | 2813582461 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 KINGWOOD MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773396400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813124000 | ||||||||
| FaxNumber: | 2813582461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLER | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER / AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2813124000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 008591 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 202351701 | 05 | TX | MEDICAID | 179919901 | 05 | TX | MEDICAID | 202351702 | 05 | TX | MEDICAID |