Provider Demographics
NPI:1821032780
Name:GLEN ROSE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:GLEN ROSE MEDICAL FOUNDATION
Other - Org Name:GLEN ROSE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-897-2215
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-0299
Mailing Address - Country:US
Mailing Address - Phone:254-897-2215
Mailing Address - Fax:254-897-1446
Practice Address - Street 1:1021 HOLDEN ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4937
Practice Address - Country:US
Practice Address - Phone:254-897-2215
Practice Address - Fax:254-897-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000059261QA1903X, 261QC0050X, 281P00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Not Answered261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Not Answered281P00000XHospitalsChronic Disease Hospital
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3367917OtherAETNA INS
TX10010265OtherAMERIGROUP
TXHH0458OtherBLUE CROSS BLUE SHEILD
TX=========OtherCOMMERICAL INS
TX450451Medicare ID - Type UnspecifiedAMB SURGERY