Provider Demographics
NPI:1013910868
Name:GCMC OF WHARTON COUNTY TEXAS, LLC
Entity Type:Organization
Organization Name:GCMC OF WHARTON COUNTY TEXAS, LLC
Other - Org Name:GULF COAST MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-650-7534
Mailing Address - Street 1:PO BOX 4869, DEPT 407A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4869
Mailing Address - Country:US
Mailing Address - Phone:480-650-7534
Mailing Address - Fax:480-219-5572
Practice Address - Street 1:10141 US 59 RD
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-7224
Practice Address - Country:US
Practice Address - Phone:979-282-6141
Practice Address - Fax:979-282-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008330261QA1903X
TX100142282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178815001Medicaid
TX45D0495923OtherCLIA # FOR LABORATORY
TXHH2802OtherBLUE CROSS SNF
TXTAX IDOther203745677
TX1363335 04Medicaid
TX1363335 06Medicaid
TX16213213594002OtherTEXAS REHAB VENDOR #
TX178815002Medicaid
TX621321359774880000OtherCHAMPUS PROVIDER #
TX178848101Medicaid
TXHH0522OtherBLUE CROSS ACUTE
TX014503OtherTDH BUREAU OF KIDNEY HLTH
TX45D0679101OtherCLIA # CARDIO BLOOD GAS
TX178815003Medicaid
TXHH0522OtherBLUE CROSS ACUTE
TXTAX IDOther203745677