Provider Demographics
NPI:1699745208
Name:NORTHEAST TEXAS PUBLIC HEALTH DISTRICT
Entity type:Organization
Organization Name:NORTHEAST TEXAS PUBLIC HEALTH DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:T
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:JR
Authorized Official - Credentials:FACHE
Authorized Official - Phone:903-535-0036
Mailing Address - Street 1:815 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-4507
Mailing Address - Country:US
Mailing Address - Phone:903-535-0033
Mailing Address - Fax:903-535-0052
Practice Address - Street 1:815 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-4507
Practice Address - Country:US
Practice Address - Phone:903-535-0033
Practice Address - Fax:903-535-0052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L37LMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID