MEDICARE: COMANCHE COUNTY MEDICAL CENTER COMPANY

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	412048192	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	00291V	OTHER	TX	ER PHYS GROUP
3	00L94G	OTHER	TX	BCBS OF TX-ER PHYS GROUP

General Provider Information

NPI Number	:	1184695231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMANCHE COUNTY MEDICAL CENTER COMPANY

Provider Business Mailing Address
First Line	:	10201 HIGHWAY 16
Second Line	:
City	:	COMANCHE
State	:	TX
Zip	:	76442-4462
Country	:	US
Telephone Number	:	254-879-4900
Fax Number	:	254-879-4990

Provider Business Practice Location Address
First Line	:	10201 HIGHWAY 16
Second Line	:
City	:	COMANCHE
State	:	TX
Zip	:	76442-4462
Country	:	US
Telephone Number	:	254-879-4900
Fax Number	:	254-879-4990

Authorized Official
Title or Position	:	CEO
Name	:	KEVIN STOREY
Credential	:
Telephone Number	:	254-879-4900

Provider Enumeration Date	:	01/27/2006
Last Update Date	:	04/25/2012

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