Provider Demographics
NPI:1093754475
Name:DALLAS COUNTY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:DALLAS COUNTY HOSPITAL DISTRICT
Other - Org Name:PEDIATRIC PRIMARY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FREDRICK
Authorized Official - Middle Name:P
Authorized Official - Last Name:CERISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-590-8006
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5151 MAPLE AVE # 6B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-8136
Practice Address - Country:US
Practice Address - Phone:214-266-0110
Practice Address - Fax:214-266-0113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111924001Medicaid
TX111924002Medicaid
TX133247005Medicaid