Provider Demographics
NPI:1336376391
Name:ST PAUL CHILDREN'S MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ST PAUL CHILDREN'S MEDICAL CORPORATION
Other - Org Name:ST PAUL CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-531-9455
Mailing Address - Street 1:1350 E RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-6153
Mailing Address - Country:US
Mailing Address - Phone:903-531-9455
Mailing Address - Fax:903-526-3118
Practice Address - Street 1:1350 E RICHARDS ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6153
Practice Address - Country:US
Practice Address - Phone:903-531-9455
Practice Address - Fax:903-526-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203740003OtherMEDICAID CSCHN
TX203740001Medicaid
TX203740002OtherMEDICAID TH STEPS