Provider Demographics
| NPI: | 1124062484 |
|---|---|
| Name: | EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES |
| Entity type: | Organization |
| Organization Name: | EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | VP |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | REBECCA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | MANGUM |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 903-596-3594 |
| 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: | 901 TURTLE CREEK DR |
| Practice Address - Street 2: | |
| Practice Address - City: | TYLER |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 75701 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 903-596-3555 |
| Practice Address - Fax: | 903-596-3560 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-06-16 |
| Last Update Date: | 2017-04-11 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207R00000X, 207RC0000X, 207RE0101X, 207V00000X, 207X00000X, 208000000X, 208100000X, 2084P0800X, 2085R0202X, 208600000X, 363A00000X, 363L00000X, 208800000X, 207Q00000X | ||
| TX | 4278 | 111N00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TX | 130864507 | Medicaid | |
| TX | 00T07K | Other | BLUE CROSS |
| TX | 130864502 | Medicaid | |
| TX | CC7791 | Other | RAILROAD MEDICARE |
| TX | CD9882 | Other | RAILROAD MEDICARE |
| TX | 4944030003 | Other | PALMETTO DME |
| TX | CC6186 | Other | RAILROAD MEDICARE |
| TX | 085332701 | Medicaid | |
| TX | 4944030003 | Medicare PIN | |
| TX | 00T62U | Medicare PIN | |
| TX | CC6186 | Other | RAILROAD MEDICARE |
| TX | 130864502 | Medicaid | |
| TX | 0086AE | Medicare PIN | |
| TX | CC7791 | Medicare PIN | |
| TX | 4944030003 | Medicare NSC | |
| TX | CD9882 | Other | RAILROAD MEDICARE |
