1639197510 NPI number — FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES

Table of content: (NPI 1639197510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639197510 NPI number — FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AMARILLO CHILDRENS CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639197510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 CARE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79124-2105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-468-6280
Provider Business Mailing Address Fax Number:
806-468-7174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 CARE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79124-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-468-6280
Provider Business Practice Location Address Fax Number:
806-468-7174
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
SUZANNE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
806-468-6280

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251B00000X , with the licence number: 675512 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 092290802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092290803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092290804 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 092290801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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