1518015908 NPI number — EAST TEXAS MEDICAL CENTER PITTSBURG

Table of content: (NPI 1518015908)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518015908 NPI number — EAST TEXAS MEDICAL CENTER PITTSBURG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER PITTSBURG
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 RURAL HEALTH CLINIC
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:
1518015908
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2009
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:
2701 U.S. HWY 271 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75686-4289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-946-5442
Provider Business Practice Location Address Fax Number:
903-946-5258
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
W
Authorized Official Middle Name:
PERRY
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
903-856-4501

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  438 , 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: 138374714 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 138374713 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: K95J . This is a "BCBS RURAL HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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