Provider Demographics
NPI:1285689133
Name:EAST TEXAS MEDICAL CENTER JACKSONVILLE
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENDRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-541-5000
Mailing Address - Street 1:501 S RAGSDALE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2467
Mailing Address - Country:US
Mailing Address - Phone:903-541-5000
Mailing Address - Fax:903-541-5067
Practice Address - Street 1:501 S RAGSDALE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-2467
Practice Address - Country:US
Practice Address - Phone:903-541-5000
Practice Address - Fax:903-541-5067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000416282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130612801Medicaid
TX00J11AOtherBCBS PROVIDER NUMBER
TX1972827822OtherDBA ETMC FIRST PHYSICIANS CLINIC RUSK
TXHH0170OtherBCBS PROVIDER NUMBER
TX130612806Medicaid
TX130612804Medicaid
TX201848301Medicaid
TX1023342755OtherDBA ETMC FIRST PHYSICIANS CLINIC FRANKSTON
TX450194Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TX130612804Medicaid