Basic Information
| Provider Information | |||||||||
| NPI: | 1437486867 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
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| OtherOrganizationName: | BONHAM PAIN MANAGEMENT CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | DRAWER C | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754180180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036407311 | ||||||||
| FaxNumber: | 9036407601 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 LIPSCOMB ST | ||||||||
| Address2: | BONHAM PAIN MANAGEMENT CLINIC | ||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754184027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036404809 | ||||||||
| FaxNumber: | 9036407601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 07/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | HODGES | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9036407311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.