1710970066 NPI number — SOUTHEAST TEXAS MEDICAL ASSOCIATES

Table of content: (NPI 1710970066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710970066 NPI number — SOUTHEAST TEXAS MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST TEXAS MEDICAL ASSOCIATES
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:
GULF COAST DIAGNOSTIC SERVICES
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:
1710970066
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2929 CALDER ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BEAUMONT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77702-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-833-9797
Provider Business Mailing Address Fax Number:
409-839-3174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2929 CALDER ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BEAUMONT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77702-1845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-233-9797
Provider Business Practice Location Address Fax Number:
409-839-3174
Provider Enumeration Date:
08/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
409-833-9797

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  R25266 , 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: 9540801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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