MEDICARE: WACO PEDIATRIC HEALTH ASSOCIATES

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	D1333	TX

General Provider Information

NPI Number	:	1891870242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WACO PEDIATRIC HEALTH ASSOCIATES

Provider Business Mailing Address
First Line	:	3115 PINE AVE
Second Line	:	1006
City	:	WACO
State	:	TX
Zip	:	76708-3247
Country	:	US
Telephone Number	:	254-756-6836
Fax Number	:	254-756-6865

Provider Business Practice Location Address
First Line	:	3115 PINE AVE
Second Line	:	1006
City	:	WACO
State	:	TX
Zip	:	76708-3247
Country	:	US
Telephone Number	:	254-756-6836
Fax Number	:	254-756-6865

Authorized Official
Title or Position	:	OWNER PRES
Name	:	DR. HARVEY SPARK
Credential	:	MD
Telephone Number	:	254-756-6836

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	08/01/2007

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