Basic Information
| Provider Information | |||||||||
| NPI: | 1669422895 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEXAS EMERGENCY ROOM SERVICES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42470 | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191012470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8003053233 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 CARL RAMERT DR | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | YOAKUM | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779954868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3612932321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | GATEWOOD | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8004447009 | ||||||||
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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 | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 170737408 | 05 | TX | MEDICAID |