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General NPI Number Information
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NPI Number | 1124075593
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Entity Type | Organization
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Legal Business Name | MEMORIAL HOSPITAL POLK COUNTY
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Dates
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Enumeration Date | 05/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1717 HIGHWAY 59 LOOP N
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City | LIVINGSTON
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State | TX
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Zip | 77351-5703
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Country | US
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Telephone | 936-631-3474
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Fax | 936-631-3475
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Provider Business Mailing Address
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Address Line | 1717 HIGHWAY 59 LOOP N
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City | LIVINGSTON
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State | TX
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Zip | 77351-5703
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Country | US
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Telephone | 936-631-3474
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Fax | 936-631-3475
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Authorized Official
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Title or Position | INSURANCE SUPERVISOR
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Name | FONDA R SULLIVAN
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Credential |
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Telephone | 936-631-3474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | H9325
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | L9581
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | K3772
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License Number State | TX
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | K2507
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | L0081
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License Number State | TX
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