Provider Demographics
NPI:1215068309
Name:PEDIATRIC ASSOCIATES OF WYLIE, P.A.
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF WYLIE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:STROTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-442-2300
Mailing Address - Street 1:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-0125
Mailing Address - Country:US
Mailing Address - Phone:972-442-2300
Mailing Address - Fax:972-442-2180
Practice Address - Street 1:501 WOODBRIDGE PARKWAY
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098
Practice Address - Country:US
Practice Address - Phone:972-442-2300
Practice Address - Fax:972-442-2180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174061501Medicaid
TX174061502Medicaid
TX0066MSOtherBCBS