Healthcare Provider Details

I. General information

NPI: 1467787648
Provider Name (Legal Business Name): EAST TEXAS MEDICAL CENTER TRINITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 PROSPECT DRIVE
TRINITY TX
75862
US

IV. Provider business mailing address

P O BOX 3169 315 PROSPECT DRIVE
TRINITY TX
75862-3169
US

V. Phone/Fax

Practice location:
  • Phone: 936-744-1100
  • Fax:
Mailing address:
  • Phone: 936-594-3595
  • Fax: 936-594-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANA LAMB
Title or Position: BUSINESS OFFICE DIRECTOR
Credential:
Phone: 936-546-3810