Organization
MEMORIAL MEDICAL CENTER OF EAST TEXAS
Active
Other names
EKG Group
Organization subpart
No
Provider details
NPI number
Authorized official
MS. FONDA R SULLIVAN (INSURANCE SUPERVISOR)
(936) 631-3474
Entity
Organization
Contact information
Practice address
1201 W FRANK AVE, LUFKIN, TX 75904-3357
(936) 631-3474
(936) 631-3475
Mailing address
1201 W FRANK AVE, LUFKIN, TX 75904-3357
(936) 631-3474
(936) 631-3475
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
E1447
TX
174400000X
Specialist
E8818
TX
174400000X
Specialist
Primary
F8398
TX
174400000X
Specialist
F8981
TX
174400000X
Specialist
G4097
TX
174400000X
Specialist
H0057
TX
174400000X
Specialist
H4425
TX
174400000X
Specialist
H9325
TX
174400000X
Specialist
J0855
TX
174400000X
Specialist
L9581
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00N10T
BLUE CROSS
TX
Enumeration date
05/23/2006
Last updated
08/22/2020
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