Provider Demographics
NPI:1215984687
Name:MEMORIAL HOSPITAL POLK COUNTY
Entity type:Organization
Organization Name:MEMORIAL HOSPITAL POLK COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:FONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-631-3474
Mailing Address - Street 1:1717 HIGHWAY 59 LOOP N
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-5703
Mailing Address - Country:US
Mailing Address - Phone:936-631-3474
Mailing Address - Fax:936-631-3475
Practice Address - Street 1:1717 HIGHWAY 59 LOOP N
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-5703
Practice Address - Country:US
Practice Address - Phone:936-631-3474
Practice Address - Fax:936-631-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6696174400000X
TX237108367500000X
TX452164367500000X
TX656746367500000X
TX422854367500000X
TX033599367500000X
TX041553367500000X
TX048803367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00479NOtherBLUE CROSS GRP
TX080663002Medicaid
TX080663002Medicaid