Basic Information
| Provider Information | |||||||||
| NPI: | 1982671491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST ST. ANTHONY'S HOSPITAL CORPORATION | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAPTIST ST. ANTHONY'S HEALTH SYSTEM-BAPTIST CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062122000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062122000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 10/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALTON | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8062125170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAPTIST ST ANTHONY'S HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 000001 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282N00000X | 000001 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 133457505 | 05 | TX | MEDICAID | 758417260 | 01 | TX | AETNA | OTHER | 133457503 | 05 | TX | MEDICAID | 133457504 | 05 | TX | MEDICAID | HH0626 | 01 | TX | BLUE CROSS | OTHER | 133457506 | 05 | TX | MEDICAID |