Provider Demographics
NPI:1598196206
Name:EBD BEMC BURLESON, LLC
Entity Type:Organization
Organization Name:EBD BEMC BURLESON, LLC
Other - Org Name:BAYLOR EMERGENCY MEDICAL CENTER AT MANSFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-637-1146
Mailing Address - Street 1:8686 NEW TRAILS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-1176
Mailing Address - Country:US
Mailing Address - Phone:713-637-1144
Mailing Address - Fax:281-292-3585
Practice Address - Street 1:1776 N. U.S. 287
Practice Address - Street 2:SUITE 100
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:214-294-6300
Practice Address - Fax:713-637-1305
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EBD BEMC BURLESON, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-05
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348928801Medicaid