Provider Demographics
NPI:1639184369
Name:EAST TEXAS MEDICAL CENTER QUITMAN
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER QUITMAN
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC MINEOLA 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:O'GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5520
Mailing Address - Street 1:P.O. BOX 1304
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-2203
Mailing Address - Country:US
Mailing Address - Phone:903-946-5519
Mailing Address - Fax:903-946-5531
Practice Address - Street 1:1220 N PACIFIC AVE
Practice Address - Street 2:STE 2
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1054
Practice Address - Country:US
Practice Address - Phone:903-569-0610
Practice Address - Fax:903-569-0676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX017624004Medicaid
TX017624006Medicaid
TX017624004Medicaid