1053711804 NPI number — NACOGDOCHES COUNTY HOSPITAL DISTRICT

Table of content: (NPI 1053711804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053711804 NPI number — NACOGDOCHES COUNTY HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NACOGDOCHES 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:
NACOGDOCHES MEMORIAL PROFESSIONAL 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:
1053711804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1204 N MOUND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75961-4027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-568-8523
Provider Business Mailing Address Fax Number:
936-568-8588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 N MOUND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-568-8523
Provider Business Practice Location Address Fax Number:
936-568-8588
Provider Enumeration Date:
08/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WALLACE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
936-568-8426

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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