Basic Information
| Provider Information | |||||||||
| NPI: | 1952531824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
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| OtherOrganizationName: | HILLCREST CORYELL MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1507 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | 2542486306 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 EAST MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GATESVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765281028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2548658251 | ||||||||
| FaxNumber: | 2542486306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| LastUpdateDate: | 07/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | WEAVER | ||||||||
| AuthorizedOfficialFirstName: | TWILA | ||||||||
| AuthorizedOfficialMiddleName: | GAIL | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE REP | ||||||||
| AuthorizedOfficialTelephone: | 2542486204 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 346 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.