Provider Demographics
NPI:1205821113
Name:EAST TEXAS MEDICAL CENTER MOUNT VERNON
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER MOUNT VERNON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-537-8000
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:903-946-5531
Practice Address - Street 1:500 SOUTH STATE HIGHWAY 37
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:TX
Practice Address - Zip Code:75457-6550
Practice Address - Country:US
Practice Address - Phone:903-537-8000
Practice Address - Fax:903-537-8125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000282282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH0350OtherBLUE CROSS HOSPITAL
TX136140401Medicaid
TX136140407Medicaid
TXHH0350OtherBLUE CROSS HOSPITAL