1437119922 NPI number — MEMORIAL HEALTH SYSTEM OF EAST TEXAS

Table of content: (NPI 1437119922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437119922 NPI number — MEMORIAL HEALTH SYSTEM OF EAST TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL HEALTH SYSTEM OF EAST 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:
HENDERSON KIDNEY DISEASE CTR
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:
1437119922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1447
Provider Second Line Business Mailing Address:
HENDERSON KIDNEY DISEASE CTN
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-634-8111
Provider Business Mailing Address Fax Number:
936-639-7827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 W FRANK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-634-8111
Provider Business Practice Location Address Fax Number:
936-639-7827
Provider Enumeration Date:
03/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREUDENBERGER
Authorized Official First Name:
JOE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
936-634-8111

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  000129 , 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: 121703605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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