Provider Demographics
NPI:1932137916
Name:MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL
Other - Org Name:HOSPICE OF DEEP EAST TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:936-568-8525
Mailing Address - Street 1:1204 N MOUND ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4027
Mailing Address - Country:US
Mailing Address - Phone:936-564-4611
Mailing Address - Fax:
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-564-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000478251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000205000Medicaid
TX000205000Medicaid
TX=========OtherTAX ID INSURANCE