1134115660 NPI number — EAST TEXAS MEDICAL CENTER QUITMAN

Table of content: (NPI 1134115660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134115660 NPI number — EAST TEXAS MEDICAL CENTER QUITMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER QUITMAN
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:
1134115660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75790-2883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-963-8303
Provider Business Mailing Address Fax Number:
903-963-5863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75790-2883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-963-8303
Provider Business Practice Location Address Fax Number:
903-963-5863
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
O'GORMAN
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL CFO
Authorized Official Telephone Number:
903-946-5500

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: 063353901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017625701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com