Provider Demographics
NPI:1760641203
Name:EAST TEXAS PHYSICIANS ALLIANCE
Entity Type:Organization
Organization Name:EAST TEXAS PHYSICIANS ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-731-4700
Mailing Address - Street 1:PO BOX 4550
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-4550
Mailing Address - Country:US
Mailing Address - Phone:903-731-4700
Mailing Address - Fax:903-731-4699
Practice Address - Street 1:4002 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8491
Practice Address - Country:US
Practice Address - Phone:903-731-4700
Practice Address - Fax:903-731-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0483768291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178799601Medicaid
TXCL8597Medicare PIN
TX178799601Medicaid