Provider Demographics
NPI:1689650616
Name:MEMORIAL HOSPITAL OF POLK COUNTY
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL OF POLK COUNTY
Other - Org Name:MEMORIAL HEALTH CENTER LIVINGSTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-8111
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:MEMOIRAL MEDICAL CENTER LIVINGSTON
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-0022
Mailing Address - Country:US
Mailing Address - Phone:936-327-4381
Mailing Address - Fax:936-327-8702
Practice Address - Street 1:1717 HIGHWAY 59 BYPASS
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351
Practice Address - Country:US
Practice Address - Phone:936-327-4381
Practice Address - Fax:936-327-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000466261QA1903X, 282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112697102Medicaid
TX112697102Medicaid
TX1689650616Medicare Oscar/Certification
450395Medicare ID - Type Unspecified