Provider Demographics
NPI:1043469638
Name:EAST TEXAS MEDICAL CENTER TRINITY
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL CENTER TRINITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CULTER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:936-546-3862
Mailing Address - Street 1:315 PROSPECT DRIVE
Mailing Address - Street 2:P O BOX 3169
Mailing Address - City:TRINITY
Mailing Address - State:TX
Mailing Address - Zip Code:75862-3169
Mailing Address - Country:US
Mailing Address - Phone:936-594-3595
Mailing Address - Fax:936-544-3816
Practice Address - Street 1:315 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862-6202
Practice Address - Country:US
Practice Address - Phone:936-594-3595
Practice Address - Fax:936-544-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX450749282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079826601Medicaid