Basic Information
Provider Information | |||||||||
NPI: | 1790729861 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORYELL MEMORIAL HEALTHCARE SYSTEM SWINGBED | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1507 WEST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | GATESVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765281024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542486204 | ||||||||
FaxNumber: | 2542486306 | ||||||||
Practice Location | |||||||||
Address1: | 1507 WEST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | GATESVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765281024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542486204 | ||||||||
FaxNumber: | 2542486306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEAVER | ||||||||
AuthorizedOfficialFirstName: | TWILA | ||||||||
AuthorizedOfficialMiddleName: | GAIL | ||||||||
AuthorizedOfficialTitleorPosition: | INS CLERK | ||||||||
AuthorizedOfficialTelephone: | 2542486204 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   | TX | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.