Basic Information
| Provider Information | |||||||||
| NPI: | 1023342755 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS MEDICAL CENTER JACKSONVILLE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ETMC FIRST PHYSICIANS CLINIC FRANKSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S RAGSDALE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757662434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035415100 | ||||||||
| FaxNumber: | 9035415068 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 NORTH FRANKSTON HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | FRANKSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757632654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038765888 | ||||||||
| FaxNumber: | 9038765889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 07/28/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENDRES | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9035415100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 213876002 | 01 | TX | THSTEPS | OTHER | 213876001 | 05 | TX | MEDICAID |