Provider Demographics
NPI:1205133287
Name:PLANO CHILDREN'S MEDICAL CLINIC
Entity type:Organization
Organization Name:PLANO CHILDREN'S MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-801-9689
Mailing Address - Street 1:PO BOX 940109
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75094-0109
Mailing Address - Country:US
Mailing Address - Phone:972-801-9689
Mailing Address - Fax:972-801-9015
Practice Address - Street 1:303 S HIGHWAY 78
Practice Address - Street 2:SUITE 106
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-3944
Practice Address - Country:US
Practice Address - Phone:972-801-9689
Practice Address - Fax:972-801-9015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLANO CHILDREN'S MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083030901Medicaid
TX083030902Medicaid