Basic Information
| Provider Information | |||||||||
| NPI: | 1689663007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GOOD SHEPHERD HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHRISTUS GOOD SHEPHERD MEDICAL CENTER - LONGVIEW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9033152000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 282N00000X | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HH0346 | 01 | TX | BLUE CROSS | OTHER | 094095902 | 05 | TX | MEDICAID | 081940103 | 05 | TX | MEDICAID |