Provider Demographics
NPI:1427366855
Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Other - Org Name:ETMC FIRST PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON-WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-535-6890
Mailing Address - Street 1:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2497
Mailing Address - Fax:
Practice Address - Street 1:1318 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2119
Practice Address - Country:US
Practice Address - Phone:903-594-2497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4944030010Medicare NSC