Basic Information
| Provider Information | |||||||||
| NPI: | 1245237593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OCHILTREE HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OCHILTREE GENERAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3101 GARRETT DR | ||||||||
| Address2: | |||||||||
| City: | PERRYTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790705323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064353606 | ||||||||
| FaxNumber: | 8064352813 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 GARRETT DR | ||||||||
| Address2: | |||||||||
| City: | PERRYTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790705323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8064353606 | ||||||||
| FaxNumber: | 8064352067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUDICE | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | PAIGE | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 8064353606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 98 | TX | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 121902403 | 05 | TX | MEDICAID | HH0612 | 01 | TX | BLUE CROSS PROVIDER NUMBE | OTHER | 001013253 | 05 | TX | MEDICAID | 086324301 | 05 | TX | MEDICAID | 100453100 | 01 | TX | FIRSTCARE ER DOCTOR | OTHER | 112704504 | 05 | TX | MEDICAID | 121902404 | 05 | TX | MEDICAID | 010798901 | 05 | TX | MEDICAID | 112704501 | 05 | TX | MEDICAID | 00J44H | 01 | TX | BLUE CROSS ER DOCTORS | OTHER | 105173100 | 01 | TX | FIRSTCARE PROVIDER NUMBER | OTHER |