Provider Demographics
NPI:1720761075
Name:SOUTHEAST TEXAS PEDIATRIC CENTER PA
Entity Type:Organization
Organization Name:SOUTHEAST TEXAS PEDIATRIC CENTER PA
Other - Org Name:SOUTHEAST TEXAS PEDIATRIC CENTER PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-729-9200
Mailing Address - Street 1:2400 HIGHWAY 365 STE 107
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6268
Mailing Address - Country:US
Mailing Address - Phone:409-729-9200
Mailing Address - Fax:409-729-9235
Practice Address - Street 1:2400 HIGHWAY 365 STE 107
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6268
Practice Address - Country:US
Practice Address - Phone:409-729-9200
Practice Address - Fax:409-729-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-11
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty