Basic Information
| Provider Information | |||||||||
| NPI: | 1780298547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORYELL HEALTH MEDICAL CLINIC MOODY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1507 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548652166 | ||||||||
| FaxNumber: | 2542480626 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 AVENUE E | ||||||||
| Address2: | |||||||||
| City: | MOODY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765573579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548652166 | ||||||||
| FaxNumber: | 2542480626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | KARA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2542483213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | ========= | 01 | TX | TIN | OTHER |