Provider Demographics
NPI:1528041191
Name:COMMUNITY HEALTH SERVICE AGENCY, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH SERVICE AGENCY, INC.
Other - Org Name:GREENVILLE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-455-5986
Mailing Address - Street 1:PO BOX 1908
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75403-1908
Mailing Address - Country:US
Mailing Address - Phone:903-455-5986
Mailing Address - Fax:903-454-4621
Practice Address - Street 1:4311 WESLEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5639
Practice Address - Country:US
Practice Address - Phone:903-455-5958
Practice Address - Fax:903-454-4514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112276402Medicaid
TX00CN31Medicare PIN
TX451822Medicare Oscar/Certification