Provider Demographics
NPI:1114222312
Name:COOK CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:COOK CHILDREN'S MEDICAL CENTER
Other - Org Name:COOK CHILDREN'S URGENT CARE SOUTHLAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RHOADES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-885-4480
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-1860
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:2727 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6613
Practice Address - Country:US
Practice Address - Phone:682-885-6000
Practice Address - Fax:682-885-6050
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK CHILDREN'S MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-19
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284673503Medicaid
453300Medicare PIN