Basic Information
| Provider Information | |||||||||
| NPI: | 1699076257 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT & WHITE HOSPITAL - MARBLE FALLS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYLOR SCOTT & WHITE CLINIC - LLANO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 102 E YOUNG ST | ||||||||
| Address2: | |||||||||
| City: | LLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786431349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252474131 | ||||||||
| FaxNumber: | 3252472562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2010 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | OLS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8302018679 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 0042WF | 01 | TX | BCBS | OTHER | 282267802 | 01 | TX | MEDICAID THSTEPS | OTHER | 282267803 | 05 | TX | MEDICAID |