Provider Demographics
NPI:1629314539
Name:EAST TEXAS MEDICAL CENTER CARTHAGE
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER CARTHAGE
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC CENTER III
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-694-4652
Mailing Address - Street 1:409 COTTAGE RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-1466
Mailing Address - Country:US
Mailing Address - Phone:903-694-4652
Mailing Address - Fax:903-694-4625
Practice Address - Street 1:305 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-1511
Practice Address - Country:US
Practice Address - Phone:936-590-4035
Practice Address - Fax:936-590-4146
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TEXAS MEDICAL CENTER CARTHAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-20
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3187015-02Medicaid
TX3187015-01Medicaid
673408Medicare Oscar/Certification