Provider Demographics
NPI:1477567360
Name:COLLEGE STATION HOSPITAL LP
Entity Type:Organization
Organization Name:COLLEGE STATION HOSPITAL LP
Other - Org Name:COLLEGE STATION MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR /AUTH OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7466
Mailing Address - Street 1:PO BOX 848526
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8526
Mailing Address - Country:US
Mailing Address - Phone:979-764-5100
Mailing Address - Fax:979-696-7373
Practice Address - Street 1:1604 ROCK PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8345
Practice Address - Country:US
Practice Address - Phone:979-764-5100
Practice Address - Fax:979-696-7373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLEGE STATION HOSPITAL LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-28
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00132TMedicare ID - Type UnspecifiedPART B, EKG READS
TX00132TMedicare PIN