Basic Information
| Provider Information | |||||||||
| NPI: | 1619124658 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS MEDICAL CENTER GILMER | ||||||||
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| OtherOrganizationName: | ETMC PHYSICANS CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1237 | ||||||||
| Address2: | |||||||||
| City: | GILMER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756441237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038417100 | ||||||||
| FaxNumber: | 9038417286 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 LINDA DR | ||||||||
| Address2: | |||||||||
| City: | DAINGERFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756382132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038417100 | ||||||||
| FaxNumber: | 9038417286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 10/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | O'GORMAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9038564520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST TEXAS MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 453406 | 01 | TX | MEDICARE RURAL HEALTH CLINIC | OTHER | 168447408 | 05 | TX | MEDICAID | 168447406 | 05 | TX | MEDICAID |