Provider Demographics
NPI:1265554000
Name:EAST TEXAS CHEST CLINIC, P.A.
Entity type:Organization
Organization Name:EAST TEXAS CHEST CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:,OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-639-6210
Mailing Address - Street 1:818 W FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3317
Mailing Address - Country:US
Mailing Address - Phone:936-639-6210
Mailing Address - Fax:936-639-2298
Practice Address - Street 1:818 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3317
Practice Address - Country:US
Practice Address - Phone:936-639-6210
Practice Address - Fax:936-639-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00046HMedicare PIN