Basic Information
| Provider Information | |||||||||
| NPI: | 1023121522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS MEDICAL CENTER CANCER INSTITUTE | ||||||||
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| OtherOrganizationName: | ETMC CANCER INSTITUTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7908 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757117908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035312371 | ||||||||
| FaxNumber: | 9035312337 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035955550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 08/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | HALE | ||||||||
| AuthorizedOfficialFirstName: | BYRON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9035356215 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00SN36 | 01 | TX | BCBS OF TEXAS | OTHER | 085049701 | 05 | TX | MEDICAID |