Provider Demographics
NPI:1710425541
Name:ST. ALYSSA MEDICAL CENTER
Entity Type:Organization
Organization Name:ST. ALYSSA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:CLINIC DIRECTOR
Authorized Official - Phone:936-645-1586
Mailing Address - Street 1:PO BOX 635312
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963
Mailing Address - Country:US
Mailing Address - Phone:936-645-1586
Mailing Address - Fax:
Practice Address - Street 1:2805 NORTH ST STE E
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2800
Practice Address - Country:US
Practice Address - Phone:936-205-3171
Practice Address - Fax:936-205-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty