Provider Demographics
NPI:1003939232
Name:DICKERSON MEMORIAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:DICKERSON MEMORIAL HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-447-6800
Mailing Address - Street 1:260 N SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-2018
Mailing Address - Country:US
Mailing Address - Phone:281-447-6800
Mailing Address - Fax:281-447-6802
Practice Address - Street 1:1001 DICKERSON DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5110
Practice Address - Country:US
Practice Address - Phone:409-383-2345
Practice Address - Fax:281-447-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007235282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH0400OtherBCBS PROVIDER ID
TX450838Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER