MEDICARE: PEDIATRIC NEUROLOGY, P.A.

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	2084N0402X	Neurology with Special Qualifications in Child Neurology Physician	H5298	TX

General Provider Information

NPI Number	:	1689862195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC NEUROLOGY, P.A.

Provider Business Mailing Address
First Line	:	3704 CARLON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3702
Country	:	US
Telephone Number	:	713-776-9111
Fax Number	:

Provider Business Practice Location Address
First Line	:	3704 CARLON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-3702
Country	:	US
Telephone Number	:	713-776-9111
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEWART BRUCE ATER
Credential	:	M.D.
Telephone Number	:	713-776-9111

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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