Basic Information
| Provider Information | |||||||||
| NPI: | 1598196206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EBD BEMC BURLESON, LLC | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAYLOR EMERGENCY MEDICAL CENTER AT MANSFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8686 NEW TRAILS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | THE WOODLANDS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773811176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136371144 | ||||||||
| FaxNumber: | 2812923585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1776 N. U.S. 287 | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142946300 | ||||||||
| FaxNumber: | 7136371305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2013 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7136371146 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EBD BEMC BURLESON, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 348928801 | 05 | TX | MEDICAID |