Provider Demographics
NPI:1437119922
Name:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Other - Org Name:HENDERSON KIDNEY DISEASE CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREUDENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-8111
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:HENDERSON KIDNEY DISEASE CTN
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902
Mailing Address - Country:US
Mailing Address - Phone:936-634-8111
Mailing Address - Fax:936-639-7827
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-634-8111
Practice Address - Fax:936-639-7827
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-27
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000129261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121703605Medicaid
452345Medicare ID - Type Unspecified
TX1437119922Medicare Oscar/Certification