Provider Demographics
NPI:1093708679
Name:ASCENSION PROVIDENCE
Entity Type:Organization
Organization Name:ASCENSION PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-324-1000
Mailing Address - Street 1:P.O. BOX 2589
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-2589
Mailing Address - Country:US
Mailing Address - Phone:254-751-4146
Mailing Address - Fax:254-751-4283
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4146
Practice Address - Fax:254-751-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-29
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000040282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112551001Medicaid
TX111829102Medicaid
TX450042Medicare ID - Type UnspecifiedPROVIDENCE HEALTH CENTER
TX111829102Medicaid