Basic Information
| Provider Information | |||||||||
| NPI: | 1780717439 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOTHER FRANCES HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2990 N BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757022149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 10/26/2010 | ||||||||
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| AuthorizedOfficialLastName: | TILLMAN | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CVOANDMEDICALSTAFF DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9035315784 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 083768401 | 05 | TX | MEDICAID | 083768402 | 05 | TX | MEDICAID |