Provider Demographics
NPI:1225173107
Name:FOREST LANE PEDIATRICS
Entity Type:Organization
Organization Name:FOREST LANE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSVENOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-284-7776
Mailing Address - Street 1:7777 FOREST LN STE B300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2510
Mailing Address - Country:US
Mailing Address - Phone:972-284-7770
Mailing Address - Fax:972-284-7780
Practice Address - Street 1:7777 FOREST LN STE B300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2510
Practice Address - Country:US
Practice Address - Phone:972-284-7770
Practice Address - Fax:972-284-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0070LMOtherBCBS