Provider Demographics
NPI:1730113085
Name:PECOS COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PECOS COUNTY MEMORIAL HOSPITAL
Other - Org Name:PECOS COUNTY MEMORIAL HOSPITAL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:432-336-4200
Mailing Address - Street 1:387 W IH 10
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2700
Mailing Address - Country:US
Mailing Address - Phone:432-336-7044
Mailing Address - Fax:432-336-2630
Practice Address - Street 1:387 W IH 10
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735
Practice Address - Country:US
Practice Address - Phone:432-336-7044
Practice Address - Fax:432-336-2630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PECOS COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX009326251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130616907Medicaid
TXHH473HOtherBCBS PROVIDER NUMBER
TXHH473HOtherBCBS PROVIDER NUMBER