Provider Demographics
NPI:1942463724
Name:VILLAGE PEDIATRICS, PA
Entity Type:Organization
Organization Name:VILLAGE PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PERDUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-249-4155
Mailing Address - Street 1:4917 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2436
Mailing Address - Country:US
Mailing Address - Phone:817-249-4155
Mailing Address - Fax:817-249-0497
Practice Address - Street 1:998 WINSCOTT RD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76126-2744
Practice Address - Country:US
Practice Address - Phone:817-249-4155
Practice Address - Fax:817-249-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0154208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1331803-06Medicaid
TX1331803-04Medicaid
TXK0154OtherSTATE MEDICAL LICENSE
TX1331803-04Medicaid