Organization
MEMORIAL HOSPITAL POLK COUNTY
Active
Other names
Anesthesia Group
Organization subpart
No
Provider details
NPI number
Authorized official
FONDA R SULLIVAN (INSURANCE SUPERVISOR)
(936) 631-3474
Entity
Organization
Contact information
Practice address
1717 HIGHWAY 59 LOOP N, LIVINGSTON, TX 77351-5703
(936) 631-3474
(936) 631-3475
Mailing address
1717 HIGHWAY 59 LOOP N, LIVINGSTON, TX 77351-5703
(936) 631-3474
(936) 631-3475
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
L6696
TX
367500000X
Certified Registered Nurse Anesthetist
033599
TX
367500000X
Certified Registered Nurse Anesthetist
041553
TX
367500000X
Certified Registered Nurse Anesthetist
048803
TX
367500000X
Certified Registered Nurse Anesthetist
237108
TX
367500000X
Certified Registered Nurse Anesthetist
422854
TX
367500000X
Certified Registered Nurse Anesthetist
452164
TX
367500000X
Certified Registered Nurse Anesthetist
656746
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00479N
BLUE CROSS GRP
TX
05
—
080663002
—
TX
Enumeration date
05/30/2006
Last updated
09/11/2025
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