Provider Demographics
NPI:1578781027
Name:SILVERLAKE PEDIATRIC CLINIC, PA
Entity Type:Organization
Organization Name:SILVERLAKE PEDIATRIC CLINIC, PA
Other - Org Name:SILVERLAKE PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NITA
Authorized Official - Middle Name:SUSHIL
Authorized Official - Last Name:GANDHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-436-3637
Mailing Address - Street 1:PO BOX 891445
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77289-1445
Mailing Address - Country:US
Mailing Address - Phone:713-436-3637
Mailing Address - Fax:713-236-3639
Practice Address - Street 1:9721 BROADWAY ST
Practice Address - Street 2:SUITE 111
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8169
Practice Address - Country:US
Practice Address - Phone:713-436-3637
Practice Address - Fax:713-436-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1818208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID(EIN)