Provider Demographics
NPI:1538114442
Name:MEMORIAL MEDICAL CENTER OF EAST TEXAS
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER OF EAST TEXAS
Other - Org Name:EKG GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:INSURANCE SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:FONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-631-3474
Mailing Address - Street 1:1201 W FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3357
Mailing Address - Country:US
Mailing Address - Phone:936-631-3474
Mailing Address - Fax:936-631-3475
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3357
Practice Address - Country:US
Practice Address - Phone:936-631-3474
Practice Address - Fax:936-631-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8398174400000X
TXG4097174400000X
TXH9325174400000X
TXL9581174400000X
TXH4425174400000X
TXJ0855174400000X
TXE8818174400000X
TXF8981174400000X
TXE1447174400000X
TXH0057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N10TOtherBLUE CROSS
TX00N10TMedicare ID - Type UnspecifiedMEDICARE GRP