Provider Demographics
NPI:1154555928
Name:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Entity type:Organization
Organization Name:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-694-5081
Mailing Address - Street 1:3533 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-1721
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 MEDICAL DR STE 201
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3105
Practice Address - Country:US
Practice Address - Phone:361-572-1045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S PHYSICIAN SERVICES OF SOUTH TEXAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-08
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX082887301Medicaid