Basic Information
| Provider Information | |||||||||
| NPI: | 1720578941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ETMC PHYSICIAN GROUP INC. | ||||||||
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| OtherOrganizationName: | UT HEALTH EAST TEXAS PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BURTON HILLS BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152963000 | ||||||||
| FaxNumber: | 6152966227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 E 5TH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757013362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931749 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2018 | ||||||||
| LastUpdateDate: | 05/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.