Provider Demographics
NPI:1952639452
Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES
Other - Org Name:FIRST PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON-WAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-535-6890
Mailing Address - Street 1:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-939-0610
Practice Address - Street 1:1123 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3646
Practice Address - Country:US
Practice Address - Phone:903-675-9526
Practice Address - Fax:903-677-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4944030005Medicare NSC