Basic Information
Provider Information | |||||||||
NPI: | 1992832521 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CORYELL MEMORIAL HEALTHCARE SYSTEM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1507 WEST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | GATESVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765281024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2548658251 | ||||||||
FaxNumber: | 2542486303 | ||||||||
Practice Location | |||||||||
Address1: | 1507 WEST MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | GATESVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 765281024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2548658251 | ||||||||
FaxNumber: | 2542486303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2007 | ||||||||
LastUpdateDate: | 01/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | CAROL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 2542486268 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 00C36C | 01 |   | MEDICARE PTAN | OTHER |