Provider Demographics
NPI:1992749857
Name:GLEN ROSE MEDICAL FOUNDATION
Entity type:Organization
Organization Name:GLEN ROSE MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-897-2215
Mailing Address - Street 1:PO BOX 2099
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-2099
Mailing Address - Country:US
Mailing Address - Phone:254-897-2215
Mailing Address - Fax:254-897-1446
Practice Address - Street 1:1021 HOLDEN ST
Practice Address - Street 2:
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4937
Practice Address - Country:US
Practice Address - Phone:254-897-2215
Practice Address - Fax:254-897-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000059207L00000X, 207P00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0050KUOtherBLUE CROSS BLUE SHIELD
TX=========OtherCIGNA
TX=========OtherGEHA
TX=========OtherUNITED HEALTHCARE
TX=========OtherHUMANA GOLD
TX=========OtherBENEFIT PLANNERS
TX=========OtherUNICARE
TX0050KUOtherBLUE CROSS BLUE SHIELD
TX=========OtherSRERLING OPTION ONE
TX=========OtherAETNA
TX=========OtherHUMANA
TX=========OtherHUMANA MILITARY
TX=========OtherPACIFICARE
TX=========OtherSECURE HORIZONS
TX=========OtherWAUSAU
TX=========OtherHEALTH SMART
TX=========OtherPHCS
TX=========OtherSRERLING OPTION ONE