Provider Demographics
NPI:1497860449
Name:EAST TEXAS NEPHROLOGY ASSOCIATION
Entity Type:Organization
Organization Name:EAST TEXAS NEPHROLOGY ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:BANKHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-526-6374
Mailing Address - Street 1:700 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2014
Mailing Address - Country:US
Mailing Address - Phone:903-526-6374
Mailing Address - Fax:903-526-4578
Practice Address - Street 1:700 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2014
Practice Address - Country:US
Practice Address - Phone:903-526-6374
Practice Address - Fax:903-526-4578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9769174400000X
TXH8527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0086HDOtherBLUE CROSS BLUE SHIELD
TX00135TMedicare ID - Type Unspecified