MEDICARE: GCMC OF WHARTON COUNTY TEXAS, 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	261QA1903X	Ambulatory Surgical Clinic/Center	008330	TX
2	282N00000X	General Acute Care Hospital	100142	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	45D0495923	OTHER	TX	CLIA # FOR LABORATORY
3	HH2802	OTHER	TX	BLUE CROSS SNF
4	TAX ID	OTHER	TX	203745677
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	16213213594002	OTHER	TX	TEXAS REHAB VENDOR #
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	621321359774880000	OTHER	TX	CHAMPUS PROVIDER #
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	HH0522	OTHER	TX	BLUE CROSS ACUTE
12	014503	OTHER	TX	TDH BUREAU OF KIDNEY HLTH
13	45D0679101	OTHER	TX	CLIA # CARDIO BLOOD GAS
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013910868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GCMC OF WHARTON COUNTY TEXAS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4869, DEPT 407A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4869
Country	:	US
Telephone Number	:	480-650-7534
Fax Number	:	480-219-5572

Provider Business Practice Location Address
First Line	:	10141 US 59 RD
Second Line	:
City	:	WHARTON
State	:	TX
Zip	:	77488-7224
Country	:	US
Telephone Number	:	979-282-6141
Fax Number	:	979-282-6036

Authorized Official
Title or Position	:	CIO
Name	:	MR. KEVIN D CRANDALL
Credential	:
Telephone Number	:	480-650-7534

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/18/2016

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