Provider Demographics
NPI:1982904165
Name:MALCOLM X PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:MALCOLM X PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:GREER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:214-428-2010
Mailing Address - Street 1:4432 MALCOLM X BLVD.
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75215
Mailing Address - Country:US
Mailing Address - Phone:214-428-2010
Mailing Address - Fax:214-428-2065
Practice Address - Street 1:4432 MALCOLM X BLVD.
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215
Practice Address - Country:US
Practice Address - Phone:214-428-2010
Practice Address - Fax:214-428-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-45458261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX121321704Medicaid
TX121321702Medicaid
TX1213217-02Medicaid
TXP66023Medicare UPIN