Provider Demographics
NPI:1326082892
Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Other - Org Name:TEXAS TRAUMA AND EMERGENCY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-595-3594
Mailing Address - Street 1:PO BOX 8659
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6210 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4413
Practice Address - Country:US
Practice Address - Phone:903-579-2800
Practice Address - Fax:903-579-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX152147801Medicaid
TXCJ9743Medicare ID - Type UnspecifiedRAILROAD GROUP NUMBER
TX00708TMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER