Provider Demographics
NPI:1609055904
Name:LIVINGSTON PEDIATRIC CLINIC PA
Entity Type:Organization
Organization Name:LIVINGSTON PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIRMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-328-8812
Mailing Address - Street 1:400 OGLETREE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-6783
Mailing Address - Country:US
Mailing Address - Phone:936-328-8812
Mailing Address - Fax:936-328-8815
Practice Address - Street 1:206 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TX
Practice Address - Zip Code:77327-4504
Practice Address - Country:US
Practice Address - Phone:281-592-6000
Practice Address - Fax:936-328-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0045LZOtherBCBS
TX0045LZOtherBCBS