Provider Demographics
NPI:1265519730
Name:PINEYWOODS DIAGNOSTIC CLINIC OF EAST TEXAS PA
Entity type:Organization
Organization Name:PINEYWOODS DIAGNOSTIC CLINIC OF EAST TEXAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:RAVINDER
Authorized Official - Middle Name:R
Authorized Official - Last Name:BACHIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-632-8787
Mailing Address - Street 1:PO BOX 151226
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-1226
Mailing Address - Country:US
Mailing Address - Phone:936-632-8787
Mailing Address - Fax:936-632-8832
Practice Address - Street 1:400 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-3416
Practice Address - Country:US
Practice Address - Phone:936-327-7733
Practice Address - Fax:936-327-2248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176384901Medicaid
TX0022MUOtherBLUECROSS & BLUESHIELD
TX176384901Medicaid