Provider Demographics
NPI:1518015908
Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Other - Org Name:ETMC FIRST PHYSICIANS RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-856-4501
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:903-946-5519
Mailing Address - Fax:903-946-5531
Practice Address - Street 1:2701 U.S. HWY 271 N
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-4289
Practice Address - Country:US
Practice Address - Phone:903-946-5442
Practice Address - Fax:903-946-5258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX438261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138374714Medicaid
TX138374713Medicaid
TXK95JOtherBCBS RURAL HEALTH
TX458850Medicare ID - Type UnspecifiedMEDICARE RHC