MEDICARE: DICKERSON MEMORIAL HOSPITAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NR1301X	Rural Acute Care Hospital	007235	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HH0400	OTHER	TX	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1003939232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DICKERSON MEMORIAL HOSPITAL, LLC

Provider Business Mailing Address
First Line	:	260 N SAM HOUSTON PKWY E
Second Line	:	SUITE 220
City	:	HOUSTON
State	:	TX
Zip	:	77060-2018
Country	:	US
Telephone Number	:	281-447-6800
Fax Number	:	281-447-6802

Provider Business Practice Location Address
First Line	:	1001 DICKERSON DR
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-5110
Country	:	US
Telephone Number	:	409-383-2345
Fax Number	:	281-447-6802

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JOHN TATUM
Credential	:
Telephone Number	:	281-447-6800

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	08/22/2020

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