1124062484 NPI number — EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES

Table of content: (NPI 1124062484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124062484 NPI number — EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER HEALTHCARE 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:
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:
1124062484
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9477
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:
75711-9477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-594-2450
Provider Business Mailing Address Fax Number:
903-939-0610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 TURTLE CREEK DR
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:
75701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-596-3555
Provider Business Practice Location Address Fax Number:
903-596-3560
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANGUM
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
903-596-3594

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4278 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 130864507 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00T07K . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 130864502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: CC7791 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CD9882 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4944030003 . This is a "PALMETTO DME" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CC6186 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 085332701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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