Basic Information
| Provider Information | |||||||||
| NPI: | 1942532106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1325 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756711325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039276611 | ||||||||
| FaxNumber: | 9039276230 | ||||||||
| Practice Location | |||||||||
| Address1: | 618 S GROVE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756705294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039276611 | ||||||||
| FaxNumber: | 9039276230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2010 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | SPROUSE | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9039276264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SHEPHERD MEDICAL CENTER MARSHALL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.