Provider Demographics
NPI:1720037559
Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Other - Org Name:ETMC PITTSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-856-4501
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 1:2701 U.S. HWY 271 N
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-4289
Practice Address - Country:US
Practice Address - Phone:903-946-5000
Practice Address - Fax:903-946-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA275N00000X
TX000438282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138374701Medicaid
HH0096OtherBCBS
TX138374706Medicaid
C635OtherBCBS
00J75TOtherBCBS
CF8842OtherPALMETTO GBA
TX45Z367Medicare Oscar/Certification
C635OtherBCBS
00J75TMedicare ID - Type Unspecified
TX138374706Medicaid