Healthcare Provider Details

I. General information

NPI: 1023775905
Provider Name (Legal Business Name): ST. JUDE'S FAMILY AND PEDIATRIC CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 MONTANA AVE
EL PASO TX
79903-4904
US

IV. Provider business mailing address

5140 MONTANA AVE
EL PASO TX
79903-4904
US

V. Phone/Fax

Practice location:
  • Phone: 915-544-8844
  • Fax:
Mailing address:
  • Phone: 915-204-3809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE C GRIEGO
Title or Position: CEO
Credential: ARNP
Phone: 915-544-8844