Provider Demographics
NPI:1124515879
Name:EAST TEXAS INFUSION CENTER, PLLC
Entity type:Organization
Organization Name:EAST TEXAS INFUSION CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HICKRESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-592-4473
Mailing Address - Street 1:935 S BAXTER AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2245
Mailing Address - Country:US
Mailing Address - Phone:903-592-4473
Mailing Address - Fax:903-592-4474
Practice Address - Street 1:935 S BAXTER AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2245
Practice Address - Country:US
Practice Address - Phone:903-592-4473
Practice Address - Fax:903-592-4474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty