Basic Information
Provider Information | |||||||||
NPI: | 1376844936 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCOTT & WHITE HOSPITAL - MARBLE FALLS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAYLOR SCOTT & WHITE CLINIC - MARBLE FALLS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 844658 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752844339 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2547242111 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 706 AVE G | ||||||||
Address2: |   | ||||||||
City: | MARBLE FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 786545866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8306938234 | ||||||||
FaxNumber: | 8306939090 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2010 | ||||||||
LastUpdateDate: | 10/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLS | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8302018679 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 100090 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 283840102 | 01 | TX | MEDICAID THSTEPS | OTHER | 0042WF | 01 | TX | BCBS | OTHER | 283840103 | 05 | TX |   | MEDICAID |