Provider Demographics
NPI:1700055001
Name:EAST TEXAS INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:EAST TEXAS INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-3995
Mailing Address - Street 1:515 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3127
Mailing Address - Country:US
Mailing Address - Phone:936-634-3995
Mailing Address - Fax:
Practice Address - Street 1:515 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3127
Practice Address - Country:US
Practice Address - Phone:936-634-3995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196347201Medicaid
TXG15469Medicare UPIN
TX00Z616Medicare PIN