Basic Information
| Provider Information | |||||||||
| NPI: | 1558693341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS MEDICAL CENTER CARTHAGE | ||||||||
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| OtherOrganizationName: | ETMC FIRST PHYSICIANS CLINIC CENTER II | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 COTTAGE RD | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756331466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036933841 | ||||||||
| FaxNumber: | 9036944625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1743 SOUTHVIEW CIR | ||||||||
| Address2: | |||||||||
| City: | CENTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759359324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365918888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 02/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | HUDSON | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9036944658 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | K7000 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.