Basic Information
| Provider Information | |||||||||
| NPI: | 1962434860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST TEXAS HEALTHCARE SYSTEM, INC | ||||||||
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| OtherOrganizationName: | WOMEN'S AND CHILDREN'S HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9633 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791059633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8063541000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 814 MARTIN RD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791076814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064684390 | ||||||||
| FaxNumber: | 8063424789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIRACLE | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8064684390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Family Planning, Non-Surgical | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 137245005 | 05 | TX | MEDICAID |