Provider Demographics
NPI:1295719227
Name:EAST TEXAS MEDICAL CENTER-GILMER
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER-GILMER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR OF BUSINESS SER
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMBRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5500
Mailing Address - Street 1:P.O. 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:903-946-5519
Mailing Address - Fax:903-946-5531
Practice Address - Street 1:712 N WOOD ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-1751
Practice Address - Country:US
Practice Address - Phone:903-841-7100
Practice Address - Fax:903-946-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008068282N00000X, 261QR1300X
261QR1300X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH1051OtherBLUE CROSS
TX00C13VOtherPHYSICIAN BCBS
TX168447403Medicaid
TX0069NEOtherRHC GROUP BCBS
TX168447402Medicaid
TX168447401Medicaid
TX0069NEOtherRHC GROUP BCBS
TX450884Medicare ID - Type Unspecified
TX168447403Medicaid
TX168447401Medicaid
TX177011702Medicaid