1306988035 NPI number — HEATON EAR NOSE AND THROAT ASSOCIATES OF EAST TEXAS P A

Table of content: (NPI 1306988035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306988035 NPI number — HEATON EAR NOSE AND THROAT ASSOCIATES OF EAST TEXAS P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEATON EAR NOSE AND THROAT ASSOCIATES OF EAST TEXAS P A
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:
ENT ASSOCIATES OF EAST TEXAS
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:
1306988035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1136 E GRANDE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75703-3982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-592-5601
Provider Business Mailing Address Fax Number:
903-595-3304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 E GRANDE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-3982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-592-5601
Provider Business Practice Location Address Fax Number:
903-595-3304
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GAMBLE
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
903-592-5601

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085099201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: CA8539 . This is a "PALMETTO, RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00T02E . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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