MEDICARE: EAST TEXAS MEDICAL CENTER

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	261QR1300X	Rural Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962483453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS MEDICAL CENTER

Provider Business Mailing Address
First Line	:	PO BOX 1304
Second Line	:
City	:	PITTSBURG
State	:	TX
Zip	:	75686-2203
Country	:	US
Telephone Number	:	936-544-5132
Fax Number	:	936-544-3792

Provider Business Practice Location Address
First Line	:	1100 E LOOP 304
Second Line	:	SUITE 200
City	:	CROCKETT
State	:	TX
Zip	:	75835-1810
Country	:	US
Telephone Number	:	936-544-5132
Fax Number	:	936-544-3792

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. TERRY CUTLER
Credential	:
Telephone Number	:	936-546-3862

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	02/24/2015

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Directions to “EAST TEXAS MEDICAL CENTER ” Practice Location

Language	Start Address	Practice Location

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