Provider Demographics
NPI:1134115660
Name:EAST TEXAS MEDICAL CENTER QUITMAN
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER QUITMAN
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC VAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:O'GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5500
Mailing Address - Street 1:113 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VAN
Mailing Address - State:TX
Mailing Address - Zip Code:75790-2883
Mailing Address - Country:US
Mailing Address - Phone:903-963-8303
Mailing Address - Fax:903-963-5863
Practice Address - Street 1:113 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN
Practice Address - State:TX
Practice Address - Zip Code:75790-2883
Practice Address - Country:US
Practice Address - Phone:903-963-8303
Practice Address - Fax:903-963-5863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063353901Medicaid
TX017625701Medicaid
TX063353901Medicaid