Provider Demographics
NPI:1194807438
Name:EAST TEXAS MEDICAL CENTER MOUNT VERNON
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER MOUNT VERNON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-537-8000
Mailing Address - Street 1:P O BOX 477
Mailing Address - Street 2:500 SOUTH STATE HWY 37
Mailing Address - City:MOUNT VERNON
Mailing Address - State:TX
Mailing Address - Zip Code:75457-0477
Mailing Address - Country:US
Mailing Address - Phone:903-537-8000
Mailing Address - Fax:903-537-8120
Practice Address - Street 1:500 HWY 37 S
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:TX
Practice Address - Zip Code:75457-6550
Practice Address - Country:US
Practice Address - Phone:903-537-8000
Practice Address - Fax:903-537-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000282282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C52SOtherBLUE CROSS CRNA
TX136140405Medicaid