East Texas Functional Medicine Center, LLC

Primary specialty

Public Health & General Preventive Medicine PhysicianTaxonomy code 2083P0901X

Legal business name

EAST TEXAS FUNCTIONAL MEDICINE CENTER, LLC

Practice address

419 WSW Loop 323 Ste 400
Tyler, TX 75701-7063

Phone

(903) 595-8077

Fax

(903) 363-1541

NPI assigned

Sep 29, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Guy Otis Danielson, MDNPI 1801905674

Title

MD/Owner

Phone

(903) 595-8077

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Integrative Health Matters Doing business as

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Guy O Danielson III, M.D.

  • Neurological Surgery Physician
  • Tyler, TX
  • NPI 1801905674
  Medicare reassignment NPD Authorized official
• Bradley Fisher, FNP-C

  • Family Nurse Practitioner
  • Tyler, TX
  • NPI 1033703749
  Medicare reassignment Care Compare group NPD
• David C Martin, M.D.,P.A.

  • Family Medicine Physician
  • Tyler, TX
  • NPI 1912013665
  Medicare reassignment Care Compare group NPD
• Kevin Glen May, M.D.

  • Internal Medicine Physician
  • Tyler, TX
  • NPI 1245339183
  Medicare reassignment Care Compare group NPD
• Cace Stuart Hurt, NP-C

  • Family Nurse Practitioner
  • Dallas, TX
  • NPI 1053720748
  Medicare reassignment NPD
• Jessica Morton

  • Family Nurse Practitioner
  • Sherman, TX
  • NPI 1760833776
  Medicare reassignment NPD
• Adam Strawbridge

  • Family Nurse Practitioner
  • Tyler, TX
  • NPI 1346928843
  Medicare reassignment NPD
• Sheri Kay Stillwell, LCSW

  • Clinical Social Worker
  • Tyler, TX
  • NPI 1154379832
  NPD
• Todd Funkhouser, M.D., PH.D

  • Allergy & Immunology (Internal Medicine) Physician
  • Las Cruces, NM
  • NPI 1326015173
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1601337600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1607299200000",
    "number": "1245847672",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "419 WSW LOOP 323 STE 400",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757017063",
            "telephone_number": "903-595-8077"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "419 WSW LOOP 323 STE 400",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757017063",
            "telephone_number": "903-595-8077",
            "fax_number": "903-363-1541"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS FUNCTIONAL MEDICINE CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-29",
        "last_updated": "2020-12-07",
        "certification_date": "2020-12-07",
        "status": "A",
        "authorized_official_last_name": "DANIELSON",
        "authorized_official_first_name": "GUY",
        "authorized_official_middle_name": "OTIS",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "903-595-8077",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2083P0901X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Preventive Medicine, Public Health & General Preventive Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DR. DANIELSON'S NPI NUMBER",
            "identifier": "1801905674",
            "state": "TX"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "419WSWLoop323Ste400TylerTX75701",
            "affiliation": "N",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "419 Wsw Loop 323 Ste 400",
            "city": "Tyler",
            "state": "TX",
            "country_code": "US",
            "postal_code": "757017063",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "info@ihm.life",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "419 Wsw Loop 323 Ste 400",
            "city": "Tyler",
            "state": "TX",
            "country_code": "US",
            "postal_code": "757017063",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Integrative Health Matters",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Integrative Health Matters",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• East Texas Family Support Clinic
• East Texas First Surgical Support PLLC
• East Texas Flight Ambulance
• East Texas Foot and Ankle Care PLLC
• East Texas Foot and Ankle Centers, PA
• East Texas Hearing AIDS, LLC
• East Texas Home Medical and Home Modifications
• East Texas Infectious Disease Consultants, PLLC
• East Texas Infusion Center, PLLC
• East Texas Lighthouse for the Blind

• Public Health & General Preventive Medicine Physician in Tyler, TX
• Providers in Tyler, TX by specialty
• Public Health & General Preventive Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 7, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.