Basic Information
| Provider Information | |||||||||
| NPI: | 1568695310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BONHAM SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 LIPSCOMB ST | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754184028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035838585 | ||||||||
| FaxNumber: | 9036407601 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 LIPSCOMB ST | ||||||||
| Address2: | |||||||||
| City: | BONHAM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754184027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036404809 | ||||||||
| FaxNumber: | 9036404950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | ZERINGUE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9036407310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FANNIN COUNTY HOSPITAL AUTHORITY | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3326597 | 05 | TX | MEDICAID |