Provider Demographics
NPI:1578542098
Name:EAST TEXAS MEDICAL CENTER FAIRFIELD
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER FAIRFIELD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOPSITAL ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-389-1616
Mailing Address - Street 1:PO BOX 1939
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 NEWMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-1419
Practice Address - Country:US
Practice Address - Phone:903-389-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000401261QA1903X, 261QR1300X, 275N00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063474302Medicaid
TXHH0713OtherBLUE CROSS BLUE SHIELD
TX063474301Medicaid
TX094190802Medicaid
TX0098DQOtherBLUE CROSS BLUE SHIELD
TX094190801Medicaid
TX458502Medicare ID - Type Unspecified
TX094190801Medicaid
TX063474302Medicaid