Provider Demographics
NPI:1942532106
Name:EAST TEXAS PEDIATRICS
Entity Type:Organization
Organization Name:EAST TEXAS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-927-6264
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1325
Mailing Address - Country:US
Mailing Address - Phone:903-927-6611
Mailing Address - Fax:903-927-6230
Practice Address - Street 1:618 S GROVE ST STE 100
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5294
Practice Address - Country:US
Practice Address - Phone:903-927-6611
Practice Address - Fax:903-927-6230
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MEDICAL CENTER MARSHALL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty