Provider Demographics
NPI:1487099248
Name:ST. JOSEPH REGIONAL HEALTH CENTER
Entity type:Organization
Organization Name:ST. JOSEPH REGIONAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-774-2079
Mailing Address - Street 1:2800 S TEXAS AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:979-690-4828
Mailing Address - Fax:979-690-4829
Practice Address - Street 1:1512 HOLLEMAN DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-3297
Practice Address - Country:US
Practice Address - Phone:979-764-6885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081951801Medicaid
TX450011Medicare PIN