Healthcare Provider Details

I. General information

NPI: 1902278377
Provider Name (Legal Business Name): CHILDREN'S BMG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 PRESTON RD
PLANO TX
75024
US

IV. Provider business mailing address

1935 MEDICAL DISTRICT DR
DALLAS TX
75235-7701
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-0518
  • Fax:
Mailing address:
  • Phone: 214-456-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JERRY LEE
Title or Position: VICE PRESIDENT OF ACCOUNTING
Credential:
Phone: 214-456-0588