1194797621 NPI number — CHRISTUS HEALTH SOUTHEAST TEXAS

Table of content: (NPI 1194797621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194797621 NPI number — CHRISTUS HEALTH SOUTHEAST TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTUS HEALTH SOUTHEAST TEXAS
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:
CHRISTUS SOUTHEAST TEXAS - FAMILY PRACTICE CENTER SAM RAYBURN
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:
1194797621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5316
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAM RAYBURN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75951-7701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-384-1872
Provider Business Mailing Address Fax Number:
409-383-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2427 W RECREATIONAL ROAD 255
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKELAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75931-6408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-698-9600
Provider Business Practice Location Address Fax Number:
409-698-2800
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIEGAND
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
409-384-1872

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , 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: 137305210 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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