1851522924 NPI number — GCMC OF WHARTON COUNTY TEXAS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851522924 NPI number — GCMC OF WHARTON COUNTY TEXAS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GCMC OF WHARTON COUNTY TEXAS, LLC
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:
GULF COAST 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:
1851522924
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4869, DEPT 407A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77210-4869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-282-6141
Provider Business Mailing Address Fax Number:
979-282-6036

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10141 US 59 RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHARTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77488-7224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-282-6141
Provider Business Practice Location Address Fax Number:
979-282-6036
Provider Enumeration Date:
08/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MONTELLO
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DIRECTOR OF BUSINESS SERVICES
Authorized Official Telephone Number:
979-282-6141

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  008330 , 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: 178848101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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