Provider Demographics
NPI:1063447159
Name:EAST TEXAS MEDICAL CENTER CLARKSVILLE
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER CLARKSVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR OF BUSINESS SER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMBRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-946-5519
Mailing Address - Street 1:PO BOX 1304
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-2203
Mailing Address - Country:US
Mailing Address - Phone:903-427-6400
Mailing Address - Fax:903-427-2719
Practice Address - Street 1:3000 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3371
Practice Address - Country:US
Practice Address - Phone:903-632-5632
Practice Address - Fax:903-427-2719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000292282NR1301X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063513801Medicaid
TX017887301Medicaid
TX063513801Medicaid