Provider Demographics
NPI:1861467193
Name:WILFORD HALL MEDICAL CENTER
Entity Type:Organization
Organization Name:WILFORD HALL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-292-6707
Mailing Address - Street 1:9911 STONEFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-6749
Mailing Address - Country:US
Mailing Address - Phone:210-706-9393
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:ATTN: CREDENTIALS (CMC)
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-6707
Practice Address - Fax:210-292-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40761286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX70319POtherWHMC PROVIDER NUMBER
TX40761OtherLCSW LICENSE NUMBER