Provider Demographics
NPI:1659638914
Name:ST MARK'S MEDICAL CENTER
Entity Type:Organization
Organization Name:ST MARK'S MEDICAL CENTER
Other - Org Name:ST MARK'S MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-242-2105
Mailing Address - Street 1:1 SAINT MARKS PL
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1250
Mailing Address - Country:US
Mailing Address - Phone:979-242-2104
Mailing Address - Fax:979-242-2204
Practice Address - Street 1:2 SAINT MARKS PL STE 110
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1255
Practice Address - Country:US
Practice Address - Phone:979-242-2387
Practice Address - Fax:979-242-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0083XMOtherBLUE CROSS
TX176692503Medicaid
TX0083XMOtherBLUE CROSS