Provider Demographics
NPI:1033376744
Name:EDMONDSON ROSS & HURST MEMORIAL CLINIC PLLC
Entity Type:Organization
Organization Name:EDMONDSON ROSS & HURST MEMORIAL CLINIC PLLC
Other - Org Name:MEMORIAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:STACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-892-2781
Mailing Address - Street 1:600 N HIGHLAND AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-5631
Mailing Address - Country:US
Mailing Address - Phone:903-870-4609
Mailing Address - Fax:903-891-2025
Practice Address - Street 1:600 N HIGHLAND AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-5631
Practice Address - Country:US
Practice Address - Phone:903-892-2781
Practice Address - Fax:903-892-2780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7908208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195685601Medicaid
TX00Z596Medicare PIN