Basic Information
| Provider Information | |||||||||
| NPI: | 1861542235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHAMBERS COUNTY PUBLIC HOSPITAL DISTRICT NO 1 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OMNI POINT HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 398 | ||||||||
| Address2: | |||||||||
| City: | ANAHUAC | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775140398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092673143 | ||||||||
| FaxNumber: | 4092673608 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HOSPITAL DR. | ||||||||
| Address2: | |||||||||
| City: | ANAHUAC | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775140398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4092673143 | ||||||||
| FaxNumber: | 4092673608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KIEFER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4092673143 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0005356055 | 01 | TX | AETNA NON HMO ER-PR FEES | OTHER | 112504901 | 05 | TX | MEDICAID | 127254404 | 05 | TX | MEDICAID | 0002556037 | 01 | TX | AETNA HMO ALL | OTHER | 0007414307 | 01 | TX | AETNA NON HMO WCMC | OTHER | 00C25L | 01 | TX | BCBS CRNA PRO FEES | OTHER |