MEDICARE: EAST TEXAS MEDICAL CENTER CROCKETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282N00000X	General Acute Care Hospital	000185	TX

General Provider Information

NPI Number	:	1073500799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS MEDICAL CENTER CROCKETT

Provider Business Mailing Address
First Line	:	PO BOX 1129
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1129
Country	:	US
Telephone Number	:	936-546-3862
Fax Number	:	936-546-3816

Provider Business Practice Location Address
First Line	:	1100 E LOOP 304
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1810
Country	:	US
Telephone Number	:	936-546-3803
Fax Number	:	936-546-3816

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	MRS. STACY BAILEY DISE
Credential	:
Telephone Number	:	936-546-3810

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	08/22/2020

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