Healthcare Provider Details

I. General information

NPI: 1548406507
Provider Name (Legal Business Name): BORGER PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 W 1ST ST STE B
BORGER TX
79007-4001
US

IV. Provider business mailing address

503 W 1ST ST STE B
BORGER TX
79007-4001
US

V. Phone/Fax

Practice location:
  • Phone: 806-274-7111
  • Fax: 806-274-7113
Mailing address:
  • Phone: 806-274-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberF0661
License Number StateTX

VIII. Authorized Official

Name: DR. KALA G SAMPAT
Title or Position: OWNER
Credential: M.D.
Phone: 806-274-7111