Provider Demographics
NPI:1326095696
Name:MEMORIAL HOSPITAL SAN AUGUSTINE
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL SAN AUGUSTINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-631-3474
Mailing Address - Street 1:511 E HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-2121
Mailing Address - Country:US
Mailing Address - Phone:936-631-3474
Mailing Address - Fax:936-631-3475
Practice Address - Street 1:511 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-2121
Practice Address - Country:US
Practice Address - Phone:936-631-3474
Practice Address - Fax:936-631-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8896174400000X
TXL9581174400000X
TXG5444174400000X
TXK3986174400000X
TXF1233174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R99CMedicare ID - Type UnspecifiedMEDICARE GRP