Provider Demographics
NPI:1518290469
Name:MALCOLM X PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:MALCOLM X PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:214-428-2010
Mailing Address - Street 1:4432 MALCOLM X BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215-4349
Mailing Address - Country:US
Mailing Address - Phone:214-428-2010
Mailing Address - Fax:214-428-2065
Practice Address - Street 1:4432 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-4349
Practice Address - Country:US
Practice Address - Phone:214-428-2010
Practice Address - Fax:214-428-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX245458363L00000X, 363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty