1992748693 NPI number — JACKSON COUNTY HOSPITAL DISTRICT

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 1992748693 NPI number — JACKSON COUNTY HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACKSON COUNTY HOSPITAL DISTRICT
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:
JACKSON MEDICAL CLINIC OF EDNA
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:
1992748693
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 S WELLS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDNA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77957-4098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-782-7800
Provider Business Mailing Address Fax Number:
361-782-7495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013A SOUTH WELLS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDNA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77957-4045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-782-3560
Provider Business Practice Location Address Fax Number:
361-782-5627
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMIGA
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
HARRISON
Authorized Official Title or Position:
ADMINISTRATOR/CFO
Authorized Official Telephone Number:
361-782-7800

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 063595501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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