Provider Demographics
NPI:1376767913
Name:KIDS CLINIC PA
Entity Type:Organization
Organization Name:KIDS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:FADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-994-7255
Mailing Address - Street 1:7017 S STAPLES ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5507
Mailing Address - Country:US
Mailing Address - Phone:361-994-7255
Mailing Address - Fax:361-994-7740
Practice Address - Street 1:7017 S STAPLES ST
Practice Address - Street 2:STE 101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5507
Practice Address - Country:US
Practice Address - Phone:361-994-7255
Practice Address - Fax:361-994-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3035305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121271401Medicaid
TX121271404Medicaid