Basic Information
| Provider Information | |||||||||
| NPI: | 1447547773 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCH PROFESSIONAL CARE HOSPITAL BASED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797602129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326402401 | ||||||||
| FaxNumber: | 4326404606 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797615001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326402401 | ||||||||
| FaxNumber: | 4326404606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2011 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | ALVARADO | ||||||||
| AuthorizedOfficialFirstName: | ADIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4326402401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MCH PROFESSIONAL CARE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 289541901 | 05 | TX | MEDICAID |