Provider Demographics
NPI:1558446419
Name:GOOD SHEPHERD MEDICAL CENTER
Entity Type:Organization
Organization Name:GOOD SHEPHERD MEDICAL CENTER
Other - Org Name:CHAMPION EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BANOS
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:903-315-2000
Mailing Address - Street 1:700 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5580
Mailing Address - Country:US
Mailing Address - Phone:903-315-2000
Mailing Address - Fax:
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341600000X, 3416L0300X, 343800000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)