Provider Demographics
NPI:1730123464
Name:HENDERSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HENDERSON MEMORIAL HOSPITAL
Other - Org Name:HENDERSON MEMORIAL HOSPITAL CRNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STOREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-655-3618
Mailing Address - Street 1:300 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-5956
Mailing Address - Country:US
Mailing Address - Phone:903-657-7541
Mailing Address - Fax:
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5956
Practice Address - Country:US
Practice Address - Phone:903-657-7541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C41HMedicare PIN