Provider Demographics
NPI:1821588047
Name:ETMC PHYSICIAN GROUP INC.
Entity Type:Organization
Organization Name:ETMC PHYSICIAN GROUP INC.
Other - Org Name:UT HEALTH EAST TEXAS PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-296-3000
Mailing Address - Street 1:1 BURTON HILLS BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6195
Mailing Address - Country:US
Mailing Address - Phone:615-296-3227
Mailing Address - Fax:615-296-6227
Practice Address - Street 1:612 N HIGH ST STE A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5914
Practice Address - Country:US
Practice Address - Phone:903-657-1441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies