Basic Information
| Provider Information | |||||||||
| NPI: | 1295719227 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS MEDICAL CENTER-GILMER | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1304 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756862203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039465519 | ||||||||
| FaxNumber: | 9039465531 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 N WOOD ST | ||||||||
| Address2: | |||||||||
| City: | GILMER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756441751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038417100 | ||||||||
| FaxNumber: | 9039465531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROLSTON | ||||||||
| AuthorizedOfficialFirstName: | TAMBRI | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR OF BUSINESS SER | ||||||||
| AuthorizedOfficialTelephone: | 9039465500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 008068 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HH1051 | 01 | TX | BLUE CROSS | OTHER | 00C13V | 01 | TX | PHYSICIAN BCBS | OTHER | 168447403 | 05 | TX | MEDICAID | 0069NE | 01 | TX | RHC GROUP BCBS | OTHER | 168447402 | 05 | TX | MEDICAID | 168447401 | 05 | TX | MEDICAID |