Provider Demographics
NPI:1821085721
Name:THE PEDIATRIC CLINIC, P.A.
Entity Type:Organization
Organization Name:THE PEDIATRIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-572-9823
Mailing Address - Street 1:2001 N JEFFERSON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TX
Mailing Address - Zip Code:75455-2371
Mailing Address - Country:US
Mailing Address - Phone:903-572-9823
Mailing Address - Fax:903-572-4812
Practice Address - Street 1:2001 N JEFFERSON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MOUNT PLEASANT
Practice Address - State:TX
Practice Address - Zip Code:75455-2371
Practice Address - Country:US
Practice Address - Phone:903-572-9823
Practice Address - Fax:903-572-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00TS61Medicare PIN