Provider Demographics
NPI:1811151046
Name:MEMORIAL MEDICAL CENTER-SAN AUGUSTINE
Entity type:Organization
Organization Name:MEMORIAL MEDICAL CENTER-SAN AUGUSTINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:AHRENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-8111
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902-1447
Mailing Address - Country:US
Mailing Address - Phone:936-275-3446
Mailing Address - Fax:936-275-9921
Practice Address - Street 1:403 NORTH MILAM STREET
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-2121
Practice Address - Country:US
Practice Address - Phone:936-275-3446
Practice Address - Fax:936-275-9921
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL MEDICAL CENTER-SAN AUGUSTINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-16
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130734007Medicaid
TX452383Medicare Oscar/Certification