Basic Information
| Provider Information | |||||||||
| NPI: | 1568455814 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST TEXAS MEDICAL ASSOCIATES | ||||||||
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| OtherOrganizationName: | GULF COAST LABORATORY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4098393174 | ||||||||
| Practice Location | |||||||||
| Address1: | 2929 CALDER ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098339797 | ||||||||
| FaxNumber: | 4098393174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 04/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | RICKS | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADM ASST CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4098393118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 45D0921403 | TX | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 0847899-02 | 05 | TX | MEDICAID | 690009531 | 01 | TX | RR MEDICARE | OTHER |