Provider Demographics
NPI:1104179910
Name:EAST TEXAS MEDICAL CENTER CLARKSVILLE
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER CLARKSVILLE
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC CLARKSVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIR OF BUSINESS SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMBRI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5519
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-2203
Mailing Address - Country:US
Mailing Address - Phone:903-946-5519
Mailing Address - Fax:
Practice Address - Street 1:3000 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3371
Practice Address - Country:US
Practice Address - Phone:903-427-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health