Basic Information
| Provider Information | |||||||||
| NPI: | 1174580138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS RADIOLOGY CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4777 US HIGHWAY 259 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756057668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036634800 | ||||||||
| FaxNumber: | 9036630378 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032323660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | PITTMON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9036634800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.