1508871278 NPI number — EAST TEXAS MEDICAL CENTER QUITMAN

Table of content: (NPI 1508871278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508871278 NPI number — EAST TEXAS MEDICAL CENTER QUITMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER QUITMAN
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:
ETMC FIRST PHYSICIANS CLINIC MINEOLA
Provider Other Organization Name Type Code:
3
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:
1508871278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75686-2203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-946-5519
Provider Business Mailing Address Fax Number:
903-946-5531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 N PACIFIC ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINEOLA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75773-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-569-6124
Provider Business Practice Location Address Fax Number:
903-569-2467
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBICHEAUX
Authorized Official First Name:
WARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL ADMINISTRATION
Authorized Official Telephone Number:
903-946-5500

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 063351301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017624001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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