MEDICARE: NORTHEAST TEXAS PEDIATRICS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1215362710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST TEXAS PEDIATRICS, PLLC

Provider Business Mailing Address
First Line	:	2001 N JEFFERSON AVE
Second Line	:	SUITE 300
City	:	MOUNT PLEASANT
State	:	TX
Zip	:	75455-2338
Country	:	US
Telephone Number	:	903-572-9823
Fax Number	:	903-572-4812

Provider Business Practice Location Address
First Line	:	2001 MULBERRY AVE
Second Line	:
City	:	MOUNT PLEASANT
State	:	TX
Zip	:	75455-2362
Country	:	US
Telephone Number	:	903-572-9823
Fax Number	:	903-572-4812

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GERALD A STAGG
Credential	:	M.D.
Telephone Number	:	903-572-9823

Provider Enumeration Date	:	09/04/2013
Last Update Date	:	09/04/2013

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