Basic Information
| Provider Information | |||||||||
| NPI: | 1558321836 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOMBALL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TOMBALL REGIONAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 889 | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773770889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814017500 | ||||||||
| FaxNumber: | 2813572273 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 HOLDERRIETH BLVD | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773756445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814017500 | ||||||||
| FaxNumber: | 2813572273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 03/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARBER | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | COO CFO EXECUTIVE VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2814017633 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOMBALL HOSPITAL AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 76 | TX | N | Hospital Units | Psychiatric Unit | 282N00000X | 00076 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0150576 | 05 | NY | MEDICAID | 06521548 | 05 | MS | MEDICAID | 1558321836 | 05 | VA | MEDICAID | 1747289 | 05 | LA | MEDICAID | 1558321836 | 05 | IA | MEDICAID | 278266 | 05 | OR | MEDICAID | 5084010 00 | 05 | ID | MEDICAID | 000107764A | 05 | GA | MEDICAID | 018709808 | 05 | MO | MEDICAID | 100701890A | 05 | OK | MEDICAID | 11462B | 05 | SC | MEDICAID | 200495280A | 05 | IN | MEDICAID | 50000105 | 05 | KY | MEDICAID | HOS0670N | 05 | AL | MEDICAID | 000A848 | 05 | NM | MEDICAID | 900906000 | 05 | FL | MEDICAID | 0164914 | 05 | OH | MEDICAID | 025785 | 05 | AZ | MEDICAID | 131044305 | 05 | TX | MEDICAID | 1510994 | 05 | TN | MEDICAID | 82563400 | 05 | WI | MEDICAID | XHSP32324 | 05 | CA | MEDICAID | 431420000 | 05 | ME | MEDICAID | 95012555 | 05 | CO | MEDICAID | 154683105 | 05 | AR | MEDICAID | 110027294B | 05 | MA | MEDICAID | 1558321836 | 05 | AL | MEDICAID | 6999905 | 05 | NJ | MEDICAID | XHSP42324 | 05 | CA | MEDICAID |