Provider Demographics
NPI:1255436135
Name:MEDICAL & SURGICAL DERMATOLOGY CENTER OF NORTHEAST TEXAS, P.A.
Entity type:Organization
Organization Name:MEDICAL & SURGICAL DERMATOLOGY CENTER OF NORTHEAST TEXAS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:V
Authorized Official - Last Name:GRECO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-577-8878
Mailing Address - Street 1:108 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-5322
Mailing Address - Country:US
Mailing Address - Phone:903-577-8878
Mailing Address - Fax:903-577-8936
Practice Address - Street 1:108 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-5322
Practice Address - Country:US
Practice Address - Phone:903-577-8878
Practice Address - Fax:903-577-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9067207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX081422001Medicaid
TX45EROtherBCBS GROUP
TX00953NMedicare ID - Type UnspecifiedGROUP
TX070015602Medicare ID - Type UnspecifiedRAILROAD MEDICARE #
TXG21218Medicare UPIN