1376777649 NPI number — EAST TEXAS MEDICAL CENTER HENDERSON

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376777649 NPI number — EAST TEXAS MEDICAL CENTER HENDERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER HENDERSON
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 HENDERSON FHC
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:
1376777649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 WILSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75652-5956
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-657-7541
Provider Business Mailing Address Fax Number:
903-657-4009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75652-5956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-657-7541
Provider Business Practice Location Address Fax Number:
903-657-4009
Provider Enumeration Date:
05/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LEITNER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
903-655-3616

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , 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: 0047SP . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 208755301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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