Basic Information
| Provider Information | |||||||||
| NPI: | 1710970066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST TEXAS MEDICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GULF COAST DIAGNOSTIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 4092339797 | ||||||||
| FaxNumber: | 4098393174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4098339797 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335V00000X | R25266 | TX | Y | Suppliers | Portable X-Ray Supplier |
ID Information
| ID | Type | State | Issuer | Description | 9540801 | 05 | TX | MEDICAID |