Healthcare Provider Details

I. General information

NPI: 1720578941
Provider Name (Legal Business Name): ETMC PHYSICIAN GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 5TH ST STE 400
TYLER TX
75701-3362
US

IV. Provider business mailing address

1 BURTON HILLS BLVD STE 250
NASHVILLE TN
37215-6195
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-1749
  • Fax:
Mailing address:
  • Phone: 615-296-3000
  • Fax: 615-296-6227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN C. PETROVICH
Title or Position: EVP
Credential:
Phone: 615-296-3000