Provider Demographics
NPI:1942484712
Name:EAST TEXAS WOMEN'S CLINIC
Entity Type:Organization
Organization Name:EAST TEXAS WOMEN'S CLINIC
Other - Org Name:CHARLES L FOUGEROUSSE MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-639-4463
Mailing Address - Street 1:401 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3132
Mailing Address - Country:US
Mailing Address - Phone:936-639-4463
Mailing Address - Fax:936-639-4417
Practice Address - Street 1:401 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3132
Practice Address - Country:US
Practice Address - Phone:936-639-4417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1548207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D933Medicare PIN
TXB22788Medicare UPIN