Provider Demographics
NPI:1336546266
Name:GOODALL-WITCHER HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:GOODALL-WITCHER HOSPITAL AUTHORITY
Other - Org Name:LAKE WHITNEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-675-8322
Mailing Address - Street 1:202 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-2398
Mailing Address - Country:US
Mailing Address - Phone:254-674-2221
Mailing Address - Fax:254-694-9978
Practice Address - Street 1:202 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2398
Practice Address - Country:US
Practice Address - Phone:254-694-2221
Practice Address - Fax:254-694-9978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX347012203Medicaid