Provider Demographics
NPI:1417511593
Name:EAST TEXAS OUT-PATIENT PLLC
Entity Type:Organization
Organization Name:EAST TEXAS OUT-PATIENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHELSEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAISATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-567-1910
Mailing Address - Street 1:PO BOX 76
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:TX
Mailing Address - Zip Code:75103-0076
Mailing Address - Country:US
Mailing Address - Phone:903-962-3419
Mailing Address - Fax:903-962-3635
Practice Address - Street 1:116 N HOUSTON ST
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:TX
Practice Address - Zip Code:75117-1555
Practice Address - Country:US
Practice Address - Phone:903-962-3419
Practice Address - Fax:903-962-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty