1962483453 NPI number — EAST TEXAS MEDICAL CENTER

Table of content: (NPI 1962483453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962483453 NPI number — EAST TEXAS MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER
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 CROCKETT FAMILY MEDICAL CENTER RHC
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:
1962483453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2015
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:
936-544-5132
Provider Business Mailing Address Fax Number:
936-544-3792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 E LOOP 304
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CROCKETT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75835-1810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-544-5132
Provider Business Practice Location Address Fax Number:
936-544-3792
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CUTLER
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
936-546-3862

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: 095181602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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