Provider Demographics
NPI:1497804371
Name:EAST TEXAS MEDICAL CENTER
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER
Other - Org Name:ETMC CRNA SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-526-1068
Mailing Address - Street 1:PO BOX 8027
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8027
Mailing Address - Country:US
Mailing Address - Phone:903-526-1068
Mailing Address - Fax:903-593-4290
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-526-1068
Practice Address - Fax:903-593-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDE1328OtherGROUP NUMBER RR MCR
TX00C99SOtherGROUP NUMBER TX BCBS
TX00925ZMedicare ID - Type UnspecifiedGROUP NUMBER TX MEDICARE