Healthcare Provider Details

I. General information

NPI: 1356320873
Provider Name (Legal Business Name): EAST TEXAS MEDICAL CENTER ATHENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S PALESTINE ST
ATHENS TX
75751-5610
US

IV. Provider business mailing address

PO BOX 1996
ATHENS TX
75751-1996
US

V. Phone/Fax

Practice location:
  • Phone: 903-675-2216
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number000374
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number000374
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number000374
License Number StateTX

VIII. Authorized Official

Name: MR. PAT WALLACE
Title or Position: ADMINISTATOR
Credential:
Phone: 903-675-1000