Healthcare Provider Details

I. General information

NPI: 1659638914
Provider Name (Legal Business Name): ST MARK'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT MARKS PL STE 110
LA GRANGE TX
78945-1255
US

IV. Provider business mailing address

1 SAINT MARKS PL
LA GRANGE TX
78945-1250
US

V. Phone/Fax

Practice location:
  • Phone: 979-242-2387
  • Fax: 979-242-2206
Mailing address:
  • Phone: 979-242-2104
  • Fax: 979-242-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY HARTFIELD
Title or Position: CHIEF CLINICAL OFFICER
Credential:
Phone: 979-242-2105