Provider Demographics
NPI: | 1629252937 |
---|---|
Name: | EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES |
Entity Type: | Organization |
Organization Name: | EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES |
Other - Org Name: | ETMC FIRST PHYSICIANS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | VICE PRESIDENT |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | KIM |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | PEARSON-WAHL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 903-535-6890 |
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: | 903-939-0610 |
Practice Address - Street 1: | 904 S BECKHAM AVE |
Practice Address - Street 2: | |
Practice Address - City: | TYLER |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75701-1906 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-596-3555 |
Practice Address - Fax: | 903-596-3560 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-12-21 |
Last Update Date: | 2007-12-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208VP0000X | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | Group - Multi-Specialty |
No | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 00T07K | Other | BLUE CROSS |
TX | CD9882 | Other | RAILROAD MEDICARE |
TX | 00T07K | Other | BLUE CROSS |
TX | CD9882 | Medicare PIN |