1073696357 NPI number — JACKSON COUNTY HOSPITAL DISTRICT

Table of content: (NPI 1073696357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073696357 NPI number — JACKSON COUNTY HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON COUNTY HOSPITAL DISTRICT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JACKSON MEDICAL CLINIC OF GANADO PHYSICIAN GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073696357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 S WELLS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77957-4098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-782-5241
Provider Business Mailing Address Fax Number:
361-782-7495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 S. THIRD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GANADO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77962-1214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-771-3571
Provider Business Practice Location Address Fax Number:
361-771-3574
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENKE
Authorized Official First Name:
MARCELLA
Authorized Official Middle Name:
VANA
Authorized Official Title or Position:
ADMINISTRATOR/CEO
Authorized Official Telephone Number:
361-782-5241

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85627001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com