Basic Information
| Provider Information | |||||||||
| NPI: | 1528195062 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORYELL MEMORIAL HEALTHCARE SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1507 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | 2542486303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1507 WEST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | 2542486303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 2542486268 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00BW86 | 01 | TX | MEDICARE PTAN | OTHER |