NPIMap

Organization Active NPI

Memorial Medical Center

  • Surgery Physician
  • Port Lavaca, TX
National Provider Identifier
1104203181
Registry record updated Jul 6, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
Legal business name
MEMORIAL MEDICAL CENTER
Practice address
815 N Virginia St
Port Lavaca, TX 77979-3025
Phone
(361) 552-6713
Fax
(361) 552-0220
NPI assigned
Apr 29, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 6, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Erin Clevenger
Title
Ceo
Phone
(361) 552-0454

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208600000X Primary

Addresses

Primary practice location

815 N Virginia St
Port Lavaca, TX 77979-3025

Mailing address

815 N Virginia St
Port Lavaca, TX 77979-3025
Phone (361) 552-6713

Other identifiers 2

IdentifierTypeStateIssuer
T225OtherTXMEDICARE PART B
137909103MedicaidTX

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040316000136 TX Part B Supplier - Clinic/Group Practice 3072403096 Receives reassigned benefits from 11 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Port Lavaca, TX

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Memorial Medical Center7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1430265600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1783296000000",
    "number": "1104203181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "815 N VIRGINIA ST",
            "city": "PORT LAVACA",
            "state": "TX",
            "postal_code": "779793025",
            "telephone_number": "361-552-6713",
            "fax_number": "361-552-0220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "815 N VIRGINIA ST",
            "city": "PORT LAVACA",
            "state": "TX",
            "postal_code": "779793025",
            "telephone_number": "361-552-6713",
            "fax_number": "361-552-0220"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-29",
        "last_updated": "2026-07-06",
        "certification_date": "2026-07-06",
        "status": "A",
        "authorized_official_last_name": "CLEVENGER",
        "authorized_official_first_name": "ERIN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "361-552-0454"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART B",
            "identifier": "T225",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "137909103",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Port Lavaca, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.