1790782704 NPI number — SID PETERSON MEMORIAL HOSPITAL

Table of content: (NPI 1790782704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790782704 NPI number — SID PETERSON MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SID PETERSON MEMORIAL HOSPITAL
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:
PETERSON REGIONAL 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:
1790782704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
551 HILL COUNTRY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KERRVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78028-6085
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-896-4200
Provider Business Mailing Address Fax Number:
830-258-7678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 HILL COUNTRY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERRVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78028-6085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-896-4200
Provider Business Practice Location Address Fax Number:
830-258-7678
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MEDOVICH
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
830-258-7632

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NR1301X , with the licence number: 000406 , 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: 127294003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH0439 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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