Memorial Hospital Polk County

Primary specialty

SpecialistTaxonomy code 174400000X

License

L0081 Issued in TX

Legal business name

MEMORIAL HOSPITAL POLK COUNTY

Practice address

1717 Highway 59 Loop N
Livingston, TX 77351-5703

Phone

(936) 631-3474

Fax

(936) 631-3475

NPI assigned

May 30, 2006

Organization subpart

No

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

Authorized official

Name

Fonda R Sullivan

Title

Insurance Supervisor

Phone

(936) 631-3474

Specialties & licenses 5

Addresses

Other names 1

• EKG Group Other name

Tax ID family

Brian Bruckner MD2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

• Memorial Hospital Polk County

  • Specialist
  • Livingston, TX
  • NPI 1215984687
  NPD tax ID

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

{
    "created_epoch": "1148947200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1124075593",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1717 HIGHWAY 59 LOOP N",
            "city": "LIVINGSTON",
            "state": "TX",
            "postal_code": "773515703",
            "telephone_number": "936-631-3474",
            "fax_number": "936-631-3475"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1717 HIGHWAY 59 LOOP N",
            "city": "LIVINGSTON",
            "state": "TX",
            "postal_code": "773515703",
            "telephone_number": "936-631-3474",
            "fax_number": "936-631-3475"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL HOSPITAL POLK COUNTY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-30",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "SULLIVAN",
        "authorized_official_first_name": "FONDA",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "INSURANCE SUPERVISOR",
        "authorized_official_telephone_number": "936-631-3474"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "TX",
            "license": "H9325",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "TX",
            "license": "L9581",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "TX",
            "license": "K3772",
            "primary": false
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "TX",
            "license": "L0081",
            "primary": true
        },
        {
            "code": "174400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Specialist",
            "state": "TX",
            "license": "K2507",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "EKG Group",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Ashitha Elizabeth Mathew, OD
• Sumorria Xzavia Mays
• Kelly McPfimeloronti, PH.D.
• Mediswan LLC
• Memorial Hospital of Polk County
• Memorial Hospital Polk County
• Mens Center for Counseling and Coaching
• Sherry Middleton, PTA
• Annise Benoit Miller, LICSW
• Eloisa Miller, PTA

• Specialist in Livingston, TX
• Providers in Livingston, TX by specialty
• Specialist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.