MEDICARE: THE PEDIATRIC CLINIC, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1437984259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PEDIATRIC CLINIC, P.A.

Provider Business Mailing Address
First Line	:	2001 N JEFFERSON AVE STE 300
Second Line	:
City	:	MOUNT PLEASANT
State	:	TX
Zip	:	75455-2375
Country	:	US
Telephone Number	:	903-572-9823
Fax Number	:	903-572-4812

Provider Business Practice Location Address
First Line	:	2001 N JEFFERSON AVE STE 300
Second Line	:
City	:	MOUNT PLEASANT
State	:	TX
Zip	:	75455-2375
Country	:	US
Telephone Number	:	903-572-9823
Fax Number	:	903-572-4812

Authorized Official
Title or Position	:	ADMINISTRTOR
Name	:	SUZAN COLVIN
Credential	:
Telephone Number	:	903-572-9823

Provider Enumeration Date	:	09/03/2024
Last Update Date	:	09/16/2025

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