Provider Demographics
NPI:1700117538
Name:LBJ MEDICAL CENTER
Entity Type:Organization
Organization Name:LBJ MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TINDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:684-633-1222
Mailing Address - Street 1:PO BOX LBJ
Mailing Address - Street 2:
Mailing Address - City:PAGO PAGO
Mailing Address - State:AS
Mailing Address - Zip Code:96799-0010
Mailing Address - Country:US
Mailing Address - Phone:684-633-1222
Mailing Address - Fax:
Practice Address - Street 1:PO BOX LBJ
Practice Address - Street 2:
Practice Address - City:PAGO PAGO
Practice Address - State:AMERICAN SAMOA
Practice Address - Zip Code:96799
Practice Address - Country:UM
Practice Address - Phone:684-633-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LBJ MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AS1097-A282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital