Provider Demographics
NPI:1003935172
Name:EAST TEXAS MEDICAL ALLIANCE LLP
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL ALLIANCE LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-723-8554
Mailing Address - Street 1:115 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4781
Mailing Address - Country:US
Mailing Address - Phone:903-723-8554
Mailing Address - Fax:903-723-2054
Practice Address - Street 1:111 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4781
Practice Address - Country:US
Practice Address - Phone:903-723-8554
Practice Address - Fax:903-723-2054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R18COtherBLUE CROSS GROUP NUMBER
TX111610501Medicaid
TX111610503OtherEPSDT GROUP NUMBER
TXCQ2287OtherRR MEDICARE NUMBER
TX111610501Medicaid