Basic Information
Provider Information | |||||||||
NPI: | 1922001312 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST TEXAS MEDICAL ASSOCIATES, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2929 CALDER ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777021845 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098339797 | ||||||||
FaxNumber: | 4096546886 | ||||||||
Practice Location | |||||||||
Address1: | 2929 CALDER ST | ||||||||
Address2: | STE 100 | ||||||||
City: | BEAUMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 777021841 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4098339797 | ||||||||
FaxNumber: | 4096546906 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2005 | ||||||||
LastUpdateDate: | 08/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOLLY | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | L. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4098339797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   | 261QM1300X | 00R45W | TX | N |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 208000000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 084789901 | 05 | TX |   | MEDICAID |