Provider Demographics
NPI:1548406507
Name:BORGER PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:BORGER PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALA
Authorized Official - Middle Name:G
Authorized Official - Last Name:SAMPAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-274-7111
Mailing Address - Street 1:503 W 1ST ST
Mailing Address - Street 2:STE B
Mailing Address - City:BORGER
Mailing Address - State:TX
Mailing Address - Zip Code:79007-4001
Mailing Address - Country:US
Mailing Address - Phone:806-274-7111
Mailing Address - Fax:
Practice Address - Street 1:503 W 1ST ST
Practice Address - Street 2:STE B
Practice Address - City:BORGER
Practice Address - State:TX
Practice Address - Zip Code:79007-4001
Practice Address - Country:US
Practice Address - Phone:806-274-7111
Practice Address - Fax:806-274-7113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0661208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112108901Medicaid
TX112108901Medicaid