Provider Demographics
NPI:1184689622
Name:EAST TEXAS KIDNEY SPECIALISTS,PA
Entity Type:Organization
Organization Name:EAST TEXAS KIDNEY SPECIALISTS,PA
Other - Org Name:EAST TEXAS KIDNEY SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-234-9992
Mailing Address - Street 1:3535 N FOURTH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0037
Mailing Address - Country:US
Mailing Address - Phone:903-234-9992
Mailing Address - Fax:903-234-8287
Practice Address - Street 1:3535 N FOURTH ST STE 301
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-0037
Practice Address - Country:US
Practice Address - Phone:903-234-9992
Practice Address - Fax:903-234-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0035GNOtherBLUE CROSS & BLUE SHIELD
TX0035GNOtherBLUE CROSS & BLUE SHIELD
TX0035GNOtherBLUE CROSS & BLUE SHIELD
TX00085RMedicare PIN