Provider Demographics
NPI:1720097694
Name:UROLOGY CENTER OF EAST TEXAS, P.A.
Entity Type:Organization
Organization Name:UROLOGY CENTER OF EAST TEXAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-675-9339
Mailing Address - Street 1:1701 SOUTH PALESTINE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-5739
Mailing Address - Country:US
Mailing Address - Phone:903-675-9339
Mailing Address - Fax:903-675-9344
Practice Address - Street 1:1701 SOUTH PALESTINE
Practice Address - Street 2:SUITE A
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5739
Practice Address - Country:US
Practice Address - Phone:903-675-9339
Practice Address - Fax:903-675-9344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0806614-03Medicaid
TX00901ROtherBCBS
TX00901RMedicare PIN