Provider Demographics
NPI:1730155995
Name:SOUTHEAST TEXAS INTERNAL MEDICINE, PA
Entity type:Organization
Organization Name:SOUTHEAST TEXAS INTERNAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTENDING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:O
Authorized Official - Last Name:GAMBRAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACP
Authorized Official - Phone:409-729-7030
Mailing Address - Street 1:PO BOX 20477
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720-0477
Mailing Address - Country:US
Mailing Address - Phone:409-729-7030
Mailing Address - Fax:409-729-7015
Practice Address - Street 1:7980 ANCHOR DR
Practice Address - Street 2:BLDG. 400
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-8266
Practice Address - Country:US
Practice Address - Phone:409-729-7030
Practice Address - Fax:409-729-7015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9675207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143474801Medicaid
TX143474801Medicaid
110220084Medicare PIN
TX00348RMedicare PIN