NPIViewer - Provider NPI 1972517365

NPI:	1972517365
Name:	COVENANT MEDICAL CENTER
Entity type:	Organization
Organization Name:	COVENANT MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:	ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:	DONALD
Authorized Official - Middle Name:	W
Authorized Official - Last Name:	ANDERSON
Authorized Official - Suffix:	JR
Authorized Official - Credentials:
Authorized Official - Phone:	425-525-5392
Mailing Address - Street 1:	3615 19TH ST
Mailing Address - Street 2:
Mailing Address - City:	LUBBOCK
Mailing Address - State:	TX
Mailing Address - Zip Code:	79410-1203
Mailing Address - Country:	US
Mailing Address - Phone:	806-725-6967
Mailing Address - Fax:	806-725-5356
Practice Address - Street 1:	3615 19TH ST
Practice Address - Street 2:
Practice Address - City:	LUBBOCK
Practice Address - State:	TX
Practice Address - Zip Code:	79410
Practice Address - Country:	US
Practice Address - Phone:	806-725-1011
Practice Address - Fax:
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2006-07-28
Last Update Date:	2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
		261QA1903X, 261QR0200X, 261QR0206X, 261QX0203X, 282N00000X, 261QR0206X, 282N00000X
TX	000465	282N00000X

Primary?	Code	Type	Classification	Specialization
Yes	282N00000X	Hospitals	General Acute Care Hospital
No	261QA1903X	Ambulatory Health Care Facilities	Clinic/Center	Ambulatory Surgical
No	261QR0200X	Ambulatory Health Care Facilities	Clinic/Center	Radiology
No	261QR0206X	Ambulatory Health Care Facilities	Clinic/Center	Radiology, Mammography
No	261QX0203X	Ambulatory Health Care Facilities	Clinic/Center	Oncology, Radiation

State	Identifier ID	ID Type	Issuer
TX	139461107	Medicaid
NM	B3151	Medicaid
AR	160265105	Medicaid
IA	592923	Medicaid
NM	A227	Other	BC/BS ACUTE
NM	B3168	Medicaid
CA	XHS41253	Medicaid
AZ	543638	Medicaid
AS	HS44IP	Medicaid
AS	HS44OP	Medicaid
TX	139461106	Medicaid
CO	48157279	Medicaid
	752765566	Other	CHAMPUS/TRICARE
TX	HH0291	Other	BLUE CROSS
CA	XHSP31253	Medicaid
KS	100395600B	Medicaid
FL	909867400	Medicaid
AL	COV0040N	Medicaid
CO	48157279	Medicaid
AS	HS44OP	Medicaid