Basic Information
| Provider Information | |||||||||
| NPI: | 1205133287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLANO CHILDREN'S MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 940109 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750940109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728019689 | ||||||||
| FaxNumber: | 9728019015 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 S HIGHWAY 78 | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | WYLIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750983944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728019689 | ||||||||
| FaxNumber: | 9728019015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 02/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHULER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9728019689 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PLANO CHILDREN'S MEDICAL CLINIC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 083030901 | 05 | TX | MEDICAID | 083030902 | 05 | TX | MEDICAID |