1285617597 NPI number — MENARD COUNTY HOSPITAL DISTRICT

Table of content: DR. MARISSA ANNE KELLOGG MD, MPH (NPI 1063642973)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285617597 NPI number — MENARD COUNTY HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENARD 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:
Provider Other Organization Name Type Code:
6
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:
1285617597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENARD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76859-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-396-4515
Provider Business Mailing Address Fax Number:
325-396-2731

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 GAY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENARD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76859-0608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-396-4515
Provider Business Practice Location Address Fax Number:
325-396-2731
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HEYMAN COMPTON
Authorized Official First Name:
BOBBI
Authorized Official Middle Name:
Authorized Official Title or Position:
MENARD MANOR ADMINISTRATOR
Authorized Official Telephone Number:
325-396-4515

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  110786 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000407502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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