Basic Information
| Provider Information | |||||||||
| NPI: | 1053615625 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIANS FOR CHILDREN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHILDREN'S HEALTH PEDIATRIC GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844582 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144564550 | ||||||||
| FaxNumber: | 2144564490 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 N STEMMONS FWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752072700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4694887100 | ||||||||
| FaxNumber: | 4694887101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2010 | ||||||||
| LastUpdateDate: | 10/06/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARR | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2144566715 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 315041907 | 05 | TX | MEDICAID | 323239904 | 05 | TX | MEDICAID | 200950804 | 05 | TX | MEDICAID | 316617501 | 05 | TX | MEDICAID | 296409004 | 05 | TX | MEDICAID | 312059404 | 05 | TX | MEDICAID | 200950807 | 05 | TX | MEDICAID | 284289001 | 05 | TX | MEDICAID | 311619604 | 05 | TX | MEDICAID | 312874604 | 05 | TX | MEDICAID | 324083001 | 05 | TX | MEDICAID | 333431001 | 05 | TX | MEDICAID | 214745601 | 05 | TX | MEDICAID | 312162604 | 05 | TX | MEDICAID | 216913801 | 05 | TX | MEDICAID | 283321201 | 05 | TX | MEDICAID |