1417456583 NPI number — BSA HOSPITAL, LLC

Table of content: (NPI 1417456583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417456583 NPI number — BSA HOSPITAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BSA HOSPITAL, 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:
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:
1417456583
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75126-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-783-0911
Provider Business Mailing Address Fax Number:
469-533-7779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 W HIGHWAY 60
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79015-7302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-336-8042
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PETROVICH
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
615-296-3000

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  1000883 , 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: 1000883 . This is a "TEXAS DEPARTMENT OF STATE HEALTH SERVICES" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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