Basic Information
| Provider Information | |||||||||
| NPI: | 1013245414 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS MEDICAL CENTER HEALTHCARE ASSOCIATES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FIRST PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9477 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757119477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035942450 | ||||||||
| FaxNumber: | 9039390610 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 OLYMPIC PLAZA CIR STE 600 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035963844 | ||||||||
| FaxNumber: | 9035963843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2009 | ||||||||
| LastUpdateDate: | 04/19/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PEARSON-WAHL | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9035356890 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.