Provider Demographics
NPI:1609382662
Name:ETMC PHYSICIAN GROUP INC.
Entity Type:Organization
Organization Name:ETMC PHYSICIAN GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP AND SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-509-0493
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-590-5611
Practice Address - Fax:903-535-6884
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHS EAST TEXAS HEALTH SYSTEM, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-28
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty