NPIMap

Organization Active NPI

Scott & White Hospital - Marble Falls

Doing business as Baylor Scott & White Clinic - San Saba

  • Rural Health Clinic/Center
  • San Saba, TX
National Provider Identifier
1902107568
Registry record updated Oct 17, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
License
100090 Issued in TX
Legal business name
SCOTT & WHITE HOSPITAL - MARBLE FALLS
Doing business as
Baylor Scott & White Clinic - San Saba
Practice address
2005 W Wallace St
San Saba, TX 76877-3928
Phone
(325) 372-5163
Fax
(325) 372-3988
NPI assigned
Nov 12, 2010
Last updated
Oct 17, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2019

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

Authorized official

Name
Timothy Ols
Title
Ceo
Phone
(830) 201-8679

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X 100090 TX Primary

Addresses

Primary practice location

2005 W Wallace St
San Saba, TX 76877-3928

Mailing address

PO Box 844658
Dallas, TX 75284-4339
Phone (254) 724-2111

Other identifiers 3

IdentifierTypeStateIssuer
285657701MedicaidTX
285657702OtherTXMEDICAID THSTEPS
0042WFOtherTXBCBS

Other names 1

  • BAYLOR SCOTT & WHITE CLINIC - SAN SABA Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191025000822 TX Part A Provider - Rural Health Clinic 6901117175 Practice locations: San Saba, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902107568. Details of each certification follow.

Rural health clinic certification: CCN 458799

Legal name
SCOTT & WHITE HOSPITAL - MARBLE FALLS
Doing business as
BAYLOR SCOTT & WHITE CLINIC - SAN SABA
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 29, 1993
Last certification
Dec 2, 2015
Ownership / control type
2B
Most recent change of ownership
Sep 1, 2019 (2 total)
Organization structure
OtherNon-profit
Incorporated
Feb 11, 2013 in TX
Enrollment address
200 E Wallace St
San Saba, TX 76877-3524
Related CCNs
450219

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D0878658Baylor Scott & White Clinic - San Saba200 East Wallace Street, San Saba, TX 76877Provider-performed microscopyMar 2, 2027

National Provider Directory

National Provider Directory
Tax ID family
Scott White Hospital - Mar7 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.

Ownership & related parties

All disclosed owners & managing parties 24

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
William Rogers Individual Operational/Managerial ControlTrustee Jul 1, 2015
Justin Meier Individual Operational/Managerial ControlSVP Corporate Finance Feb 9, 2023
Mark L Montgomery Individual Operational/Managerial ControlTrustee Nov 1, 2015
Morris E Foster Individual Operational/Managerial ControlTrustee Jul 1, 2015
Mark W English Individual Operational/Managerial ControlTrustee Jul 1, 2022
Tresa Muir McNeal Individual Operational/Managerial ControlTrustee Nov 30, 2017
Thomas Burdett Individual Operational/Managerial ControlTrustee Jul 1, 2015
Terry Maness Individual Operational/Managerial ControlTrustee Feb 23, 2019
Baylor Scott & White Health Organization, Temple, TX Corporation, Non-profit Operational/Managerial Control Sep 1, 2019
Dominic Lucia Individual Operational/Managerial ControlTrustee Dec 4, 2020
William D Digaetano Individual Operational/Managerial ControlTrustee Jul 1, 2019
Muralidhar Jatla Individual Operational/Managerial ControlTrustee Jul 1, 2023
Timothy Ols Individual Corporate DirectorCeo Sep 1, 2019
W-2 Managing EmployeeCeo Sep 1, 2019
Operational/Managerial ControlCeo Sep 1, 2019
Jim Kruse Individual Operational/Managerial ControlTrustee Jul 1, 2015
Nelda Trevino Individual Operational/Managerial ControlTrustee Dec 4, 2020
Jason Cole Individual Corporate DirectorCfo Mar 29, 2024
W-2 Managing EmployeeCfo Mar 29, 2024
Operational/Managerial ControlCfo Mar 29, 2024
Scott & White Hospital - Marble Falls Organization, Marble Falls, TX Corporation, Non-profit 5% Or Greater Indirect Ownership Interest Sep 1, 2019 100%
Aval-NA'Ree S Green Individual Operational/Managerial ControlTrustee Jul 1, 2023
Angel Eduardo Caldera Individual Operational/Managerial ControlTrustee Nov 30, 2017
Arundhati Rao Individual Operational/Managerial ControlTrustee Dec 4, 2020
Kristen Leslie Manos Individual Corporate DirectorBoard Director Jul 1, 2025
Andra Liemandt Individual Operational/Managerial ControlTrustee Jul 1, 2023
Jarvis Parsons Individual Operational/Managerial ControlTrustee Jul 1, 2024
Megan Kiella Individual Corporate DirectorBoard Director Jul 1, 2025

Owners & managing parties with NPI records 15

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

View all 15

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Baylor Scott & White Clinic - Horseshoe BayHorseshoe Bay, TX, CCN 458839 Rural health clinic 5% Or Greater Indirect Ownership Interest (100%) Sep 1, 2019
Baylor Scott & White Clinic - KingslandKingsland, TX, CCN 458686 Rural health clinic 5% Or Greater Indirect Ownership Interest (100%) Sep 1, 2019
Baylor Scott & White Clinic - Johnson CityJohnson City, TX, CCN 673417 Rural health clinic 5% Or Greater Indirect Ownership Interest (100%) Sep 1, 2019
Baylor Scott & White Clinic - Marble FallsMarble Falls, TX, CCN 458693 Rural health clinic 5% Or Greater Indirect Ownership Interest (100%) Sep 1, 2019
Baylor Scott & White Clinic - LlanoLlano, TX, CCN 453413 Rural health clinic 5% Or Greater Indirect Ownership Interest (100%) Sep 1, 2019

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 36

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 36

Change-of-ownership history 2

DateEventCounterparty
Sep 1, 2019 Change of OwnershipThis provider was the buyer Baylor Scott & White Medical Center-LlanoCCN 458799, TX, NPI 1902107568
Sep 1, 2019 Change of OwnershipThis provider was the seller Baylor Scott & White Clinic - San SabaCCN 458799, TX, NPI 1902107568

NPI Registry JSON

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

{
    "created_epoch": "1289520000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1571270400000",
    "number": "1902107568",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 844658",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "752844339",
            "telephone_number": "254-724-2111",
            "fax_number": "325-248-2109"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2005 W WALLACE ST",
            "city": "SAN SABA",
            "state": "TX",
            "postal_code": "768773928",
            "telephone_number": "325-372-5163",
            "fax_number": "325-372-3988"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SCOTT & WHITE HOSPITAL - MARBLE FALLS",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-11-12",
        "last_updated": "2019-10-17",
        "status": "A",
        "authorized_official_last_name": "OLS",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "830-201-8679"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TX",
            "license": "100090",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "285657701",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAID THSTEPS",
            "identifier": "285657702",
            "state": "TX"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "0042WF",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "BAYLOR SCOTT & WHITE CLINIC - SAN SABA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Saba, TX

Sources for this page

Verify at the official NPI Registry.