Provider Demographics
NPI:1710970066
Name:SOUTHEAST TEXAS MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST TEXAS MEDICAL ASSOCIATES
Other - Org Name:GULF COAST DIAGNOSTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:409-833-9797
Mailing Address - Street 1:2929 CALDER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1845
Mailing Address - Country:US
Mailing Address - Phone:409-833-9797
Mailing Address - Fax:409-839-3174
Practice Address - Street 1:2929 CALDER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1845
Practice Address - Country:US
Practice Address - Phone:409-233-9797
Practice Address - Fax:409-839-3174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR25266335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9540801Medicaid
TX9540801Medicaid
TX459881Medicare PIN
TX690009531Medicare PIN