1821366170 NPI number — EAST TEXAS MEDICAL CENTER JACKSONVILLE

Table of content: (NPI 1821366170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821366170 NPI number — EAST TEXAS MEDICAL CENTER JACKSONVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS MEDICAL CENTER JACKSONVILLE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ETMC FIRST PHYSICIANS CLINIC JACKSONVILLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821366170
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 S RAGSDALE ST
Provider Second Line Business Mailing Address:
ADMINISTRATION
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75766-2434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-541-5100
Provider Business Mailing Address Fax Number:
903-541-5068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 NACOGDOCHES ST
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75766-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-541-5396
Provider Business Practice Location Address Fax Number:
903-541-5393
Provider Enumeration Date:
12/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ENDRES
Authorized Official First Name:
JACK
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
903-541-5100

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130612807 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130612808 . This is a "THSTEPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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