Provider Demographics
NPI:1972827822
Name:EAST TEXAS MEDICAL CENTER JACKSONVILLE
Entity Type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER JACKSONVILLE
Other - Org Name:ETMC FIRST PHYSICIANS CLINIC RUSK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENDRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-541-5100
Mailing Address - Street 1:501 S RAGSDALE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-2434
Mailing Address - Country:US
Mailing Address - Phone:903-541-5100
Mailing Address - Fax:903-541-5068
Practice Address - Street 1:1325 N DICKINSON DR
Practice Address - Street 2:
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785-1051
Practice Address - Country:US
Practice Address - Phone:903-683-3600
Practice Address - Fax:903-683-3692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX283515901Medicaid
TX283515902OtherTHSTEPS
TX283515902OtherTHSTEPS