Provider Demographics
NPI:1104197417
Name:PEDIAMED NIGHT CLINIC-9740
Entity Type:Organization
Organization Name:PEDIAMED NIGHT CLINIC-9740
Other - Org Name:PEDIAMED NIGHT CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-227-0137
Mailing Address - Street 1:2931 GEORGE DIETER DR
Mailing Address - Street 2:STE F
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-2941
Mailing Address - Country:US
Mailing Address - Phone:915-227-0137
Mailing Address - Fax:915-208-4014
Practice Address - Street 1:9740 DYER ST
Practice Address - Street 2:STE 111
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4752
Practice Address - Country:US
Practice Address - Phone:915-867-4321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIAMED NIGHT CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty