Provider Demographics
NPI:1619092780
Name:EAST TEXAS MEDICAL CENTER SPECIALTY HOSPITAL
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER SPECIALTY HOSPITAL
Other - Org Name:EAST TEXAS MEDICAL CENTER SPECIALTY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP-COO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-596-3258
Mailing Address - Street 1:701 OLYMPIC PLAZA CIR
Mailing Address - Street 2:ADMINISTRATION
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1950
Mailing Address - Country:US
Mailing Address - Phone:903-596-3258
Mailing Address - Fax:903-596-3006
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-596-3258
Practice Address - Fax:903-596-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000777282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX020812603Medicaid
TX020812603Medicaid