Provider Demographics
NPI: | 1932640349 |
---|---|
Name: | ASSOCIATED CLINICIANS OF EAST TEXAS |
Entity Type: | Organization |
Organization Name: | ASSOCIATED CLINICIANS OF EAST TEXAS |
Other - Org Name: | DIAGNOSTIC CLINIC OF LONGVIEW |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CREDENTIALING COORDINATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MELANIE |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | PERKINS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 903-757-6042 |
Mailing Address - Street 1: | PO BOX 29343 |
Mailing Address - Street 2: | |
Mailing Address - City: | BELFAST |
Mailing Address - State: | ME |
Mailing Address - Zip Code: | 04915-2045 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-757-6042 |
Mailing Address - Fax: | 903-232-8226 |
Practice Address - Street 1: | 707 HOLLYBROOK DR |
Practice Address - Street 2: | |
Practice Address - City: | LONGVIEW |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75605-2410 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-757-6042 |
Practice Address - Fax: | 903-232-8226 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-03-17 |
Last Update Date: | 2024-02-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207K00000X | Allopathic & Osteopathic Physicians | Allergy & Immunology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207RS0012X | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 379209503 | Medicaid | |
TX | 379209501 | Medicaid |