Provider Demographics
NPI:1073842514
Name:ST. PAUL CHILDREN'S MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ST. PAUL CHILDREN'S MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SALEEN
Authorized Official - Middle Name:RHONDA
Authorized Official - Last Name:HEARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-531-9455
Mailing Address - Street 1:PO BOX 1238
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1358 E RICHARDS ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6153
Practice Address - Country:US
Practice Address - Phone:903-531-9455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty