Basic Information
| Provider Information | |||||||||
| NPI: | 1265519730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEYWOODS DIAGNOSTIC CLINIC OF EAST TEXAS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 151226 | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759151226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366328787 | ||||||||
| FaxNumber: | 9366328832 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773513416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9363277733 | ||||||||
| FaxNumber: | 9363272248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | BACHIREDDY | ||||||||
| AuthorizedOfficialFirstName: | RAVINDER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9366328787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176384901 | 05 | TX | MEDICAID | 0022MU | 01 | TX | BLUECROSS & BLUESHIELD | OTHER |