MEDICARE: MEMORIAL MEDICAL CENTER

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	282NC0060X	Critical Access Hospital	000487	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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
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	HH0489	OTHER	TX	BLUE CROSS
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689630865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL MEDICAL CENTER

Provider Business Mailing Address
First Line	:	815 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-3025
Country	:	US
Telephone Number	:	361-552-6713
Fax Number	:	361-552-0338

Provider Business Practice Location Address
First Line	:	815 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-3025
Country	:	US
Telephone Number	:	361-552-6713
Fax Number	:	361-552-0338

Authorized Official
Title or Position	:	CEO
Name	:	ERIN CLEVENGER
Credential	:
Telephone Number	:	361-552-0240

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	03/02/2026

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Directions to “MEMORIAL MEDICAL CENTER ” Practice Location

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