Provider Demographics
NPI:1790782704
Name:SID PETERSON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SID PETERSON MEMORIAL HOSPITAL
Other - Org Name:PETERSON REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-258-7632
Mailing Address - Street 1:551 HILL COUNTRY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6085
Mailing Address - Country:US
Mailing Address - Phone:830-896-4200
Mailing Address - Fax:830-258-7678
Practice Address - Street 1:551 HILL COUNTRY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6085
Practice Address - Country:US
Practice Address - Phone:830-896-4200
Practice Address - Fax:830-258-7678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
TX000406282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127294003Medicaid
TXHH0439OtherBLUE CROSS BLUE SHIELD
TX450007Medicare Oscar/Certification
TXHH0439OtherBLUE CROSS BLUE SHIELD