Provider Demographics
NPI:1134166226
Name:CONCHO COUNTY HOSPITAL
Entity type:Organization
Organization Name:CONCHO COUNTY HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF STAFF
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:OTTO
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-869-5911
Mailing Address - Street 1:614 EAKER ST
Mailing Address - Street 2:BOX 987
Mailing Address - City:EDEN
Mailing Address - State:TX
Mailing Address - Zip Code:76837-0987
Mailing Address - Country:US
Mailing Address - Phone:325-869-5911
Mailing Address - Fax:325-869-5911
Practice Address - Street 1:614 EAKER STREET
Practice Address - Street 2:BOX 987
Practice Address - City:EDEN
Practice Address - State:TX
Practice Address - Zip Code:76837-0987
Practice Address - Country:US
Practice Address - Phone:325-869-5911
Practice Address - Fax:325-869-5911
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCHO COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-31
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000202282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00650RMedicare Oscar/Certification
TX451325Medicare ID - Type Unspecified