Provider Demographics
NPI:1194877340
Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER PITTSBURG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-856-4501
Mailing Address - Street 1:414 QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:75686-1032
Mailing Address - Country:US
Mailing Address - Phone:903-856-6663
Mailing Address - Fax:903-856-4531
Practice Address - Street 1:402 S GREER BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:TX
Practice Address - Zip Code:75686-1700
Practice Address - Country:US
Practice Address - Phone:903-856-7437
Practice Address - Fax:903-856-3067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000438261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX458853Medicare ID - Type UnspecifiedGENERAL SURGERY MEDICARE