Provider Demographics
NPI:1235282112
Name:CAPITAL PEDIATRIC GROUP ASSOCIATES
Entity Type:Organization
Organization Name:CAPITAL PEDIATRIC GROUP ASSOCIATES
Other - Org Name:CAPITAL PEDIATRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:CAROLE
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-454-4545
Mailing Address - Street 1:1100 W 39TH 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3902
Mailing Address - Country:US
Mailing Address - Phone:512-454-4545
Mailing Address - Fax:512-279-0445
Practice Address - Street 1:1100 W 39TH 1/2 ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3902
Practice Address - Country:US
Practice Address - Phone:512-454-4545
Practice Address - Fax:512-279-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0921208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111533901Medicaid