Provider Demographics
NPI:1063498657
Name:NORTHEAST TEXAS SURGERY CENTER
Entity Type:Organization
Organization Name:NORTHEAST TEXAS SURGERY CENTER
Other - Org Name:NORTHEAST TEXAS SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-792-2108
Mailing Address - Street 1:1902 MOORES LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4610
Mailing Address - Country:US
Mailing Address - Phone:903-792-2108
Mailing Address - Fax:903-792-0606
Practice Address - Street 1:1902 MOORES LN
Practice Address - Street 2:SUITE B
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4610
Practice Address - Country:US
Practice Address - Phone:903-792-2108
Practice Address - Fax:903-792-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008109261QA1903X
TX008678261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR10517OtherAR BCBS
TXHH1366OtherTX BCBS ID
AR126632128Medicaid
TX176285801Medicaid
TXHH1366OtherTX BCBS ID