Provider Demographics
NPI:1639197510
Name:FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:FLETCHER AND O'GRADY PEDIATRIC ASSOCIATES
Other - Org Name:AMARILLO CHILDRENS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-468-6280
Mailing Address - Street 1:17 CARE CIR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-2105
Mailing Address - Country:US
Mailing Address - Phone:806-468-6280
Mailing Address - Fax:806-468-7174
Practice Address - Street 1:17 CARE CIR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79124-2105
Practice Address - Country:US
Practice Address - Phone:806-468-6280
Practice Address - Fax:806-468-7174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 261QP2000X
TX675512251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092290802Medicaid
TX092290803Medicaid
TX092290804Medicaid
TX092290801Medicaid