Provider Demographics
NPI:1548235906
Name:EAST TEXAS MEDICAL CENTER TRINITY
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER TRINITY
Other - Org Name:ETMC TRINITY COMMUNITY RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5520
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:936-594-3595
Mailing Address - Fax:936-594-2418
Practice Address - Street 1:315 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862-6202
Practice Address - Country:US
Practice Address - Phone:936-594-3595
Practice Address - Fax:936-594-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121817402Medicaid
TX458782Medicare Oscar/Certification