1558693341 NPI number — EAST TEXAS MEDICAL CENTER CARTHAGE

Table of content: (NPI 1558693341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558693341 NPI number — EAST TEXAS MEDICAL CENTER CARTHAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER CARTHAGE
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 CENTER II
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:
1558693341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
409 COTTAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTHAGE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75633-1466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-693-3841
Provider Business Mailing Address Fax Number:
903-694-4625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1743 SOUTHVIEW CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75935-9324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-591-8888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HUDSON
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
903-694-4658

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  K7000 , 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)





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