Provider Demographics
NPI:1598743825
Name:WILFORD HALL MEDICAL CENTER
Entity Type:Organization
Organization Name:WILFORD HALL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR CREDENTIALS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:GS-09
Authorized Official - Phone:210-292-6707
Mailing Address - Street 1:2200 BERGQUIST DR
Mailing Address - Street 2:ATTN: CREDENTIALS (CMC)
Mailing Address - City:LACKLAND AFB,
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5300
Mailing Address - Country:US
Mailing Address - Phone:210-292-6707
Mailing Address - Fax:210-292-7964
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:ATTN: CREDENTIALS (CMC)
Practice Address - City:LACKLAND AFB,
Practice Address - State:TX
Practice Address - Zip Code:78236-5300
Practice Address - Country:US
Practice Address - Phone:210-292-6707
Practice Address - Fax:210-292-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS14188282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access