Healthcare Provider Details

I. General information

NPI: 1962833228
Provider Name (Legal Business Name): COOK CHILDREN'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MATLOCK RD
MANSFIELD TX
76063-9174
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 817-347-8400
  • Fax: 681-347-8495
Mailing address:
  • Phone: 682-885-1860
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number000332
License Number StateTX

VIII. Authorized Official

Name: CORY R RHOADES
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 682-885-4480