Provider Demographics
NPI:1801847728
Name:CENTER FOR PEDIATRIC SURGERY LTD
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRIC SURGERY LTD
Other - Org Name:COOK CHILDRENS PEDIATRIC SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:972-300-0215
Mailing Address - Street 1:PO BOX 731115
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1115
Mailing Address - Country:US
Mailing Address - Phone:972-300-0237
Mailing Address - Fax:972-300-0231
Practice Address - Street 1:4200 W UNIVERSITY DR STE 110
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-9805
Practice Address - Country:US
Practice Address - Phone:972-300-0215
Practice Address - Fax:972-300-0231
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOK CHILDREN'S MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176023302Medicaid
TX45C0001398Medicare PIN