Basic Information
| Provider Information | |||||||||
| NPI: | 1821366170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS MEDICAL CENTER JACKSONVILLE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ETMC FIRST PHYSICIANS CLINIC JACKSONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S RAGSDALE ST | ||||||||
| Address2: | ADMINISTRATION | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757662434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035415100 | ||||||||
| FaxNumber: | 9035415068 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 NACOGDOCHES ST | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757662444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035415396 | ||||||||
| FaxNumber: | 9035415393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 11/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | ENDRES | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9035415100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 130612807 | 05 | TX | MEDICAID | 130612808 | 01 | TX | THSTEPS | OTHER |