Provider Demographics
NPI:1558682443
Name:ST. LUKE'S HOSPITAL AT THE VINTAGE LLC
Entity Type:Organization
Organization Name:ST. LUKE'S HOSPITAL AT THE VINTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-355-2189
Mailing Address - Street 1:3100 MAIN ST STE 663D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-9312
Mailing Address - Country:US
Mailing Address - Phone:832-355-5949
Mailing Address - Fax:832-355-7492
Practice Address - Street 1:20171 CHASEWOOD PARK DRIVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070
Practice Address - Country:US
Practice Address - Phone:832-355-3862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. LUKE'S HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-15
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219386401Medicaid
TX219386401Medicaid