Provider Demographics
NPI:1457307175
Name:PECOS COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PECOS COUNTY MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-336-4880
Mailing Address - Street 1:387 WEST IH 10
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2700
Mailing Address - Country:US
Mailing Address - Phone:432-336-2058
Mailing Address - Fax:432-336-4511
Practice Address - Street 1:387 WEST IH 10
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2700
Practice Address - Country:US
Practice Address - Phone:432-336-2058
Practice Address - Fax:844-824-3604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0079AEOtherBCBS GROUP NUMBER
TX091939102Medicaid
TX091939103Medicaid
TX0079AEMedicare PIN
TX0079AEOtherBCBS GROUP NUMBER