Provider Demographics
NPI:1356320873
Name:EAST TEXAS MEDICAL CENTER ATHENS
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER ATHENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-675-1000
Mailing Address - Street 1:PO BOX 1996
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-1996
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5610
Practice Address - Country:US
Practice Address - Phone:903-675-2216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-12
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000374261QR1300X, 261QA1903X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139713209Medicaid
TX0088DQOtherBLUE CROSS BLUE SHIELD
TX139173207Medicaid
TXHH0406OtherBLUE CROSS BLUE SHIELD
TX139173211Medicaid
TX139173213Medicaid
TX673410Medicare Oscar/Certification
TX450389Medicare ID - Type Unspecified
TXHH0406OtherBLUE CROSS BLUE SHIELD
TX00A99WMedicare ID - Type UnspecifiedRADIOLOGY PRO FEE