1578547345 NPI number — MEMORIAL MEDICAL CENTER SAN AUGUSTINE

Table of content: (NPI 1578547345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578547345 NPI number — MEMORIAL MEDICAL CENTER SAN AUGUSTINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEMORIAL MEDICAL CENTER SAN AUGUSTINE
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:
CHI ST. LUKE'S HEALTH MEMORIAL SAN AUGUSTINE
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:
1578547345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 1447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75902-1447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-275-3446
Provider Business Mailing Address Fax Number:
936-275-9921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 E HOSPITAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN AUGUSTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75972-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-275-3446
Provider Business Practice Location Address Fax Number:
936-275-9921
Provider Enumeration Date:
12/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GLASS
Authorized Official First Name:
MEGAN
Authorized Official Middle Name:
Authorized Official Title or Position:
REIMBURSEMENT ANALYST
Authorized Official Telephone Number:
936-639-7661

Provider Taxonomy Codes

  • Taxonomy code: 261QE0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 282NR1301X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3 . This is a "LIMITED SERVICES RURAL HOSPITAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130734007 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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