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General NPI Number Information
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NPI Number | 1417511593
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Entity Type | Organization
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Legal Business Name | EAST TEXAS OUT-PATIENT PLLC
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Dates
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Enumeration Date | 04/24/2019
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 116 N HOUSTON ST
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City | EDGEWOOD
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State | TX
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Zip | 75117-1555
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Country | US
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Telephone | 903-962-3419
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Fax | 903-385-3340
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Provider Business Mailing Address
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Address Line | PO BOX 76
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City | CANTON
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State | TX
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Zip | 75103-0076
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Country | US
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Telephone | 903-962-3419
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Fax | 903-962-3635
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Authorized Official
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Title or Position | OWNER
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Name | JIMMY W DAILEY
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Credential |
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Telephone | 903-567-1910
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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