Provider Demographics
NPI:1649306200
Name:ALLEN CHILDREN'S CLINIC, PA
Entity type:Organization
Organization Name:ALLEN CHILDREN'S CLINIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:TALUKDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-359-0000
Mailing Address - Street 1:600 W MCDERMOTT DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-8064
Mailing Address - Country:US
Mailing Address - Phone:972-359-0000
Mailing Address - Fax:972-359-1000
Practice Address - Street 1:600 W MCDERMOTT DR
Practice Address - Street 2:SUITE B
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-8064
Practice Address - Country:US
Practice Address - Phone:972-359-0000
Practice Address - Fax:972-359-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1088207Q00000X, 208000000X, 2080A0000X
TXK8485207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00464NMedicare ID - Type UnspecifiedGROUP ID