MEDICARE: EAST TEXAS FAMILY HEALTHCARE, PLLC

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	207Q00000X	Family Medicine Physician
2	208000000X	Pediatrics Physician	K1016	TX
3	207R00000X	Internal Medicine Physician	L0429	TX

General Provider Information

NPI Number	:	1770754335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS FAMILY HEALTHCARE, PLLC

Provider Business Mailing Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1273 S PEACHTREE ST
Second Line	:
City	:	JASPER
State	:	TX
Zip	:	75951-4915
Country	:	US
Telephone Number	:	409-384-9200
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KALYAN KUMAR RATH
Credential	:	M.D.
Telephone Number	:	409-384-9200

Provider Enumeration Date	:	03/21/2008
Last Update Date	:	09/07/2022

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