Basic Information
| Provider Information | |||||||||
| NPI: | 1477567360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE STATION HOSPITAL LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE STATION MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848526 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797645100 | ||||||||
| FaxNumber: | 9796967373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 ROCK PRAIRIE RD | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778458345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797645100 | ||||||||
| FaxNumber: | 9796967373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 11/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR /AUTH OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLLEGE STATION HOSPITAL LP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.