Provider Demographics
NPI:1689630865
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-552-6713
Mailing Address - Street 1:815 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-3025
Mailing Address - Country:US
Mailing Address - Phone:361-552-6713
Mailing Address - Fax:361-552-0338
Practice Address - Street 1:815 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-3025
Practice Address - Country:US
Practice Address - Phone:361-552-6713
Practice Address - Fax:361-552-0338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000487282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137909104Medicaid
TX137909107Medicaid
TX137909111Medicaid
TX137909101Medicaid
TX022476801Medicaid
TX142448301Medicaid
TXHH0489OtherBLUE CROSS
TX137909103Medicaid
TX137909103Medicaid
TX457762Medicare ID - Type UnspecifiedMEDICARE HOME HEALTH
TX451356Medicare ID - Type Unspecified
TX137909104Medicaid
TX137909101Medicaid
TX45Z356Medicare Oscar/Certification