Provider Demographics
NPI:1710010418
Name:GRAPEVINE PEDIATRIC CLINIC, PA
Entity Type:Organization
Organization Name:GRAPEVINE PEDIATRIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-488-7334
Mailing Address - Street 1:1600 W COLLEGE ST STE 60
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3580
Mailing Address - Country:US
Mailing Address - Phone:817-488-7334
Mailing Address - Fax:817-421-6527
Practice Address - Street 1:1600 W COLLEGE ST STE 60
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3580
Practice Address - Country:US
Practice Address - Phone:817-488-7334
Practice Address - Fax:817-421-6527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty