Basic Information
| Provider Information | |||||||||
| NPI: | 1982666111 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HERMANN HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL HERMANN HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301208 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133384127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6411 FANNIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137046614 | ||||||||
| FaxNumber: | 7137044798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 02/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | LARAWAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7132422707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416A0800X | N | Transportation Services | Ambulance | Air Transport | 3416L0300X | N | Transportation Services | Ambulance | Land Transport | 291U00000X | TX | N | Laboratories | Clinical Medical Laboratory | 261QA1903X | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282N00000X | 000347 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 137805108 | 05 | TX | MEDICAID | 137805103 | 05 | TX | MEDICAID | 137805107 | 05 | TX | MEDICAID | 112796102 | 05 | TX | MEDICAID | HH0196 | 01 | BCBS | OTHER |