MEDICARE: STONEWALL MEMORIAL HOSPITAL

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	207P00000X	Emergency Medicine Physician	00G24G	TX
2	207Q00000X	Family Medicine Physician	D4789	TX
3	207Q00000X	Family Medicine Physician	J6646	TX
4	2084P0800X	Psychiatry Physician	H9774	TX
5	261QC0050X	Critical Access Hospital Clinic/Center	453986	TX
6	261QR1300X	Rural Health Clinic/Center	453986	TX
7	275N00000X	Medicare Defined Swing Bed Hospital Unit	000666	TX
8	291U00000X	Clinical Medical Laboratory	45D0600750	TX
9	363L00000X	Nurse Practitioner	F0906010	TX
10	282NC0060X	Critical Access Hospital	000666	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	451318	OTHER	TX	MEDICARE
9	127312001	OTHER	TX	MEDICARE/MEDICAID CROSSOVER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1649378712	OTHER	TX	NP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1538142617	OTHER	TX	PHYSICIAN
4	1972577963	OTHER	TX	PHYSICIAN
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083612121
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONEWALL MEMORIAL HOSPITAL

Provider Business Mailing Address
First Line	:	821 N BROADWAY ST
Second Line	:
City	:	ASPERMONT
State	:	TX
Zip	:	79502-2029
Country	:	US
Telephone Number	:	940-989-3551
Fax Number	:	940-989-3662

Provider Business Practice Location Address
First Line	:	821 N BROADWAY ST
Second Line	:
City	:	ASPERMONT
State	:	TX
Zip	:	79502-2029
Country	:	US
Telephone Number	:	940-989-3551
Fax Number	:	940-989-3662

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL MOORHEAD
Credential	:
Telephone Number	:	940-989-3551

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	02/05/2024

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Practice Location Address:

931 N BROADWAY ST
ASPERMONT, TX
79502-2029

Practice Phone: 940-989-3551
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1710925359 — MARY GWEN GORMAN M.D.
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1457489171 — MRS. TAMMY RENAY GENTRY MPT
Practice Location Address:

821 N BROADWAY ST
ASPERMONT, TX
79502-2029

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Practice Fax: 940-989-3395

1255464392 — STONEWALL COUNTY AMBULANCE SERVICE
Practice Location Address:

821 N BROADWAY ST
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1184057598 — STONEWALL MEMORIAL HOSPITAL
Practice Location Address:

819 N BROADWAY ST
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79502-2029

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1235556002 — WHITNEY SHUMAKER
Practice Location Address:

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79502-2029

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Directions to “STONEWALL MEMORIAL HOSPITAL ” Practice Location

Language	Start Address	Practice Location

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