Basic Information
| Provider Information | |||||||||
| NPI: | 1730188822 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST TEXAS MEDICAL CENTER PITTSBURG | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ETMC HOME CARE - PITTSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 208 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756861630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038566554 | ||||||||
| FaxNumber: | 9038560084 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756861630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038566554 | ||||||||
| FaxNumber: | 9038560084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | TRACI | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | AREA DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9035356056 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 001731 | TX | Y | Agencies | Home Health |
No ID Information.