Provider Demographics
NPI:1073500799
Name:EAST TEXAS MEDICAL CENTER CROCKETT
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER CROCKETT
Other - Org Name:ETMC CROCKETT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:DISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-546-3810
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:CROCKETT
Mailing Address - State:TX
Mailing Address - Zip Code:75835-1129
Mailing Address - Country:US
Mailing Address - Phone:936-546-3862
Mailing Address - Fax:936-546-3816
Practice Address - Street 1:1100 E LOOP 304
Practice Address - Street 2:
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1810
Practice Address - Country:US
Practice Address - Phone:936-546-3803
Practice Address - Fax:936-546-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000185282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX450580Medicare Oscar/Certification