1013910868 NPI number — GCMC OF WHARTON COUNTY TEXAS, LLC

Table of content: (NPI 1013910868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013910868 NPI number — GCMC OF WHARTON COUNTY TEXAS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GCMC OF WHARTON COUNTY TEXAS, LLC
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:
GULF COAST MEDICAL CENTER
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:
1013910868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4869, DEPT 407A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77210-4869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-650-7534
Provider Business Mailing Address Fax Number:
480-219-5572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10141 US 59 RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHARTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77488-7224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-282-6141
Provider Business Practice Location Address Fax Number:
979-282-6036
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CRANDALL
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CIO
Authorized Official Telephone Number:
480-650-7534

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  008330 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 100142 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 178815001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D0495923 . This is a "CLIA # FOR LABORATORY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH2802 . This is a "BLUE CROSS SNF" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: TAX ID . This is a "203745677" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1363335 04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1363335 06 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16213213594002 . This is a "TEXAS REHAB VENDOR #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 178815002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 621321359774880000 . This is a "CHAMPUS PROVIDER #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 178848101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH0522 . This is a "BLUE CROSS ACUTE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 014503 . This is a "TDH BUREAU OF KIDNEY HLTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D0679101 . This is a "CLIA # CARDIO BLOOD GAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 178815003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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