Provider Demographics
NPI:1467787648
Name:EAST TEXAS MEDICAL CENTER TRINITY
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER TRINITY
Other - Org Name:ETMC TRINITY PRO FEES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-546-3810
Mailing Address - Street 1:P O BOX 3169
Mailing Address - Street 2:315 PROSPECT DRIVE
Mailing Address - City:TRINITY
Mailing Address - State:TX
Mailing Address - Zip Code:75862-3169
Mailing Address - Country:US
Mailing Address - Phone:936-594-3595
Mailing Address - Fax:936-594-0491
Practice Address - Street 1:317 PROSPECT DRIVE
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862
Practice Address - Country:US
Practice Address - Phone:936-744-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00086HMedicare Oscar/Certification