Provider Demographics
NPI:1790897189
Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC MOUNT VERNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-537-8000
Mailing Address - Street 1:PO 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:903-537-8222
Mailing Address - Fax:
Practice Address - Street 1:506 SOUTH STATE HWY 37
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:TX
Practice Address - Zip Code:75457-0477
Practice Address - Country:US
Practice Address - Phone:903-537-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4587261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136140406Medicaid
TX00L04LOtherBLUE CROSS ETMC RHC
TX136140410Medicaid
TX136140408Medicaid
TX136140408Medicaid