Provider Demographics
NPI:1508871245
Name:EAST TEXAS MEDICAL CENTER QUITMAN
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER QUITMAN
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC QUITMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP AFFILIATE OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5500
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-2203
Mailing Address - Country:US
Mailing Address - Phone:903-763-6220
Mailing Address - Fax:903-946-5531
Practice Address - Street 1:117 N WINNSBORO ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-2144
Practice Address - Country:US
Practice Address - Phone:903-763-6220
Practice Address - Fax:903-946-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172427001Medicaid
TX172427002Medicaid
TX458852Medicare ID - Type Unspecified