Provider Demographics
NPI:1467510271
Name:ST. JOSEPH REGIONAL HEALTH CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH REGIONAL HEALTH CENTER
Other - Org Name:ST. JOSEPH SOMERVILLE FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT FINANCIAL SERVICES MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-776-2426
Mailing Address - Street 1:PO BOX 202536
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-2536
Mailing Address - Country:US
Mailing Address - Phone:979-776-2426
Mailing Address - Fax:979-776-5948
Practice Address - Street 1:600 MEMORY LANE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TX
Practice Address - Zip Code:77879-0995
Practice Address - Country:US
Practice Address - Phone:979-776-2426
Practice Address - Fax:979-776-5948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000679261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063335601Medicaid
TX192459901Medicaid
TX018213101OtherEPSDT
TX192459901Medicaid