1063498657 NPI number — NORTHEAST TEXAS SURGERY CENTER

Table of content: (NPI 1063498657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063498657 NPI number — NORTHEAST TEXAS SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST TEXAS SURGERY 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:
Provider Other Organization Name Type Code:
6
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:
1063498657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1902 MOORES LN
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-2108
Provider Business Mailing Address Fax Number:
903-792-0606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1902 MOORES LN
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-2108
Provider Business Practice Location Address Fax Number:
903-792-0606
Provider Enumeration Date:
12/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BURNHAM
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
JO
Authorized Official Title or Position:
ASC DIRECTOR
Authorized Official Telephone Number:
903-792-2108

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  008109 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X , with the licence number: 008678 , 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: 10517 . This is a "AR BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: HH1366 . This is a "TX BCBS ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 126632128 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176285801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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