Provider Demographics
NPI:1891870242
Name:WACO PEDIATRIC HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:WACO PEDIATRIC HEALTH ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-756-6836
Mailing Address - Street 1:3115 PINE AVE
Mailing Address - Street 2:1006
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3247
Mailing Address - Country:US
Mailing Address - Phone:254-756-6836
Mailing Address - Fax:254-756-6865
Practice Address - Street 1:3115 PINE AVE
Practice Address - Street 2:1006
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3247
Practice Address - Country:US
Practice Address - Phone:254-756-6836
Practice Address - Fax:254-756-6865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1333208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E77701Medicare UPIN