Provider Demographics
NPI:1114985876
Name:GOOD SHEPHERD MEDICAL CENTER - LINDEN, INC
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL CENTER - LINDEN, INC
Other - Org Name:GOOD SHEPHERD GLENN-GARRETT CLINIC - JEFFERSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:D
Authorized Official - Last Name:BANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-315-1811
Mailing Address - Street 1:404 N KAUFMAN ST
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:TX
Mailing Address - Zip Code:75563-5234
Mailing Address - Country:US
Mailing Address - Phone:903-756-5581
Mailing Address - Fax:903-756-5005
Practice Address - Street 1:903 N WALCOTT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:TX
Practice Address - Zip Code:75657-1128
Practice Address - Country:US
Practice Address - Phone:903-665-9500
Practice Address - Fax:903-665-9501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MEDICAL CENTER - LINDEN, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-03
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0504760001OtherDME
00H878OtherBC BS OF TEXAS
127650OtherSUPERIOR
TX130943706Medicaid
CP3371OtherRAILROAD MEDICARE
0504760001OtherDME