Provider Demographics
NPI:1396748430
Name:EAST TEXAS MEDICAL CENTER QUITMAN
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER QUITMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-763-6336
Mailing Address - Street 1:117 N WINNSBORO ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75783-2144
Mailing Address - Country:US
Mailing Address - Phone:903-763-6300
Mailing Address - Fax:903-763-6140
Practice Address - Street 1:117 N WINNSBORO ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-2144
Practice Address - Country:US
Practice Address - Phone:903-763-6300
Practice Address - Fax:903-763-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000411282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX017624003Medicaid
TX017624002Medicaid
TX451380Medicare PIN
TX45Z380Medicare PIN