Provider Demographics
NPI:1083848352
Name:EAST TEXAS MEDICAL CENTER HENDERSON
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER HENDERSON
Other - Org Name:ETMC HENDERSON CRNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEITNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-655-3616
Mailing Address - Street 1:300 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652-5956
Mailing Address - Country:US
Mailing Address - Phone:903-657-7541
Mailing Address - Fax:903-657-4009
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5956
Practice Address - Country:US
Practice Address - Phone:903-657-7541
Practice Address - Fax:903-657-4009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TEXAS MEDICAL CENTER HENDERSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-14
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220328301Medicaid
TXTXB113653Medicare Oscar/Certification