Provider Demographics
NPI:1881749901
Name:EAST TEXAS PHYSCIAN'S ALLIANCE
Entity type:Organization
Organization Name:EAST TEXAS PHYSCIAN'S ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEC
Authorized Official - Middle Name:
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-723-8800
Mailing Address - Street 1:PO BOX 4550
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75802-4550
Mailing Address - Country:US
Mailing Address - Phone:903-731-4700
Mailing Address - Fax:903-731-4699
Practice Address - Street 1:112 E OAK ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-2800
Practice Address - Country:US
Practice Address - Phone:903-731-4700
Practice Address - Fax:903-731-4699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N54FMedicare ID - Type Unspecified