Provider Demographics
NPI:1942616024
Name:PEDIATRIC ENDOCRINE AND DIABETES ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC ENDOCRINE AND DIABETES ASSOCIATES, PLLC
Other - Org Name:GENESIS PEDIATRIC ENDOCRINOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHRIRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISHNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-502-6465
Mailing Address - Street 1:5105 S MCCOLL RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8278
Mailing Address - Country:US
Mailing Address - Phone:956-307-9254
Mailing Address - Fax:949-863-2674
Practice Address - Street 1:5105 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8278
Practice Address - Country:US
Practice Address - Phone:956-307-9254
Practice Address - Fax:949-863-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3540221Medicaid