Provider Demographics
NPI:1962483453
Name:EAST TEXAS MEDICAL CENTER
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER
Other - Org Name:ETMC CROCKETT FAMILY MEDICAL CENTER RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-546-3862
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-2203
Mailing Address - Country:US
Mailing Address - Phone:936-544-5132
Mailing Address - Fax:936-544-3792
Practice Address - Street 1:1100 E LOOP 304
Practice Address - Street 2:SUITE 200
Practice Address - City:CROCKETT
Practice Address - State:TX
Practice Address - Zip Code:75835-1810
Practice Address - Country:US
Practice Address - Phone:936-544-5132
Practice Address - Fax:936-544-3792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX095181602Medicaid
TX453411Medicare ID - Type Unspecified