1598059776 NPI number — PEDIATRIC URGENT CARE PA

Table of content: (NPI 1598059776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598059776 NPI number — PEDIATRIC URGENT CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC URGENT CARE PA
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:
Provider Other Organization Name Type Code:
6
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:
1598059776
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 RIVER RUN STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76107-6547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1640 LAKE WOODLANDS DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-3276
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-729-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
214-729-5600

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: H3835 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 334442604 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345142901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345650101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 346449201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 334442605 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345988501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344917501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345871301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344911801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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