1285689133 NPI number — EAST TEXAS MEDICAL CENTER JACKSONVILLE

Table of content: (NPI 1285689133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285689133 NPI number — EAST TEXAS MEDICAL CENTER JACKSONVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER JACKSONVILLE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285689133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S RAGSDALE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75766-2467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-541-5000
Provider Business Mailing Address Fax Number:
903-541-5067

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 S RAGSDALE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75766-2467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-541-5000
Provider Business Practice Location Address Fax Number:
903-541-5067
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENDRES
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
903-541-5000

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  000416 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130612801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00J11A . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1972827822 . This is a "DBA ETMC FIRST PHYSICIANS CLINIC RUSK" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH0170 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130612806 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130612804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201848301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1023342755 . This is a "DBA ETMC FIRST PHYSICIANS CLINIC FRANKSTON" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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