Provider Demographics
NPI:1205903564
Name:DEPARTMENT OF STATE HEALTH SERVICES
Entity type:Organization
Organization Name:DEPARTMENT OF STATE HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:915-834-7680
Mailing Address - Street 1:2301 N BIG SPRING ST STE 300
Mailing Address - Street 2:HSR 9/10 ATTN: BEKI HAMMONTREE
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-4534
Mailing Address - Country:US
Mailing Address - Phone:432-571-4142
Mailing Address - Fax:432-571-4153
Practice Address - Street 1:2301 N BIG SPRING ST STE 300
Practice Address - Street 2:HSR 9/10 ATTN: BEKI HAMMONTREE
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-7649
Practice Address - Country:US
Practice Address - Phone:432-571-4142
Practice Address - Fax:432-571-4153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QA0005X, 261QF0050X, 261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPH0012Medicare PIN