Basic Information
| Provider Information | |||||||||
| NPI: | 1710985098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TIRR MEMORIAL HERMANN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301208 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133384127 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 MOURSUND ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137995000 | ||||||||
| FaxNumber: | 7133384158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7132422707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 283X00000X | 000164 | TX | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | 138003201 | 05 | TX | MEDICAID | 138003210 | 05 | TX | MEDICAID | 4538530 | 01 | TX | AETNA INSURANCE | OTHER | 138003209 | 05 | TX | MEDICAID | 138003202 | 05 | TX | MEDICAID | 138003205 | 05 | TX | MEDICAID | 337433201 | 05 | TX | MEDICAID | 337433207 | 05 | TX | MEDICAID | 138003207 | 05 | TX | MEDICAID | HH0696 | 01 | TX | BLUE CROSS | OTHER |