Provider Demographics
NPI:1336376391
Name:ST. PAUL CHILDREN'S MEDICAL CORPORATION
Entity type:Organization
Organization Name:ST. PAUL CHILDREN'S MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATIONS OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-531-9455
Mailing Address - Street 1:1350 E RICHARDS ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-6153
Mailing Address - Country:US
Mailing Address - Phone:903-531-9455
Mailing Address - Fax:903-526-3118
Practice Address - Street 1:1350 E RICHARDS ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-6153
Practice Address - Country:US
Practice Address - Phone:903-531-9455
Practice Address - Fax:903-526-3118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203740002OtherMEDICAID TH STEPS
TX203740003OtherMEDICAID CSCHN
TX203740001Medicaid