Healthcare Provider Details

I. General information

NPI: 1073582656
Provider Name (Legal Business Name): SID PETERSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CULLY DR
KERRVILLE TX
78028-5950
US

IV. Provider business mailing address

551 HILL COUNTRY DR
KERRVILLE TX
78028-6085
US

V. Phone/Fax

Practice location:
  • Phone: 830-258-7400
  • Fax: 830-896-5859
Mailing address:
  • Phone: 830-257-3111
  • Fax: 830-896-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number002114
License Number StateTX

VIII. Authorized Official

Name: LISA MEDOVICH
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 830-258-7632