Healthcare Provider Details

I. General information

NPI: 1114105574
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF GEORGETOWN, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 THOUSAND OAKS BLVD
GEORGETOWN TX
78628-8757
US

IV. Provider business mailing address

103 THOUSAND OAKS BLVD
GEORGETOWN TX
78628-8757
US

V. Phone/Fax

Practice location:
  • Phone: 512-930-7337
  • Fax: 512-868-9817
Mailing address:
  • Phone: 512-930-7337
  • Fax: 512-868-9817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL MCBRIDE
Title or Position: OFFICE MANAGER
Credential:
Phone: 512-930-7337