Provider Demographics
NPI:1841564929
Name:EAST TEXAS NEUROLOGY
Entity type:Organization
Organization Name:EAST TEXAS NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHI
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-597-3787
Mailing Address - Street 1:1301 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2239
Mailing Address - Country:US
Mailing Address - Phone:903-597-3787
Mailing Address - Fax:
Practice Address - Street 1:1301 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2239
Practice Address - Country:US
Practice Address - Phone:903-597-3787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD70802084N0400X
TXE20952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
130010459OtherRAILROAD MEDICARE
1609803436OtherNPI
826133177OtherRAILROAD MEDICARE
00P572OtherBLUE CROSS
TX128085101Medicaid
00ET94OtherBLUE CROSS
TX135730301Medicaid
1184652141OtherNPI
TX135730301Medicaid
B27172Medicare UPIN