Basic Information
| Provider Information | |||||||||
| NPI: | 1235162777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS MEDICAL SPECIALISTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9229 LYNDON B JOHNSON FWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727393097 | ||||||||
| FaxNumber: | 9727392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 E MARSHALL AVE | ||||||||
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| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756015580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033152000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | UPCHURCH | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9033152445 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 165657101 | 05 | TX | MEDICAID | 0008LT | 01 | TX | BCBS | OTHER |