Provider Demographics
NPI:1700099207
Name:GRANBURY PEDIATRICS & ASSOCIATES
Entity type:Organization
Organization Name:GRANBURY PEDIATRICS & ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALCOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-579-8687
Mailing Address - Street 1:805 PALUXY RD
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-2329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 PALUXY RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-2329
Practice Address - Country:US
Practice Address - Phone:817-579-8687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6711208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82942YOtherBCBS
TX7240025OtherAETNA
TX10026584Medicaid
TX276279OtherSCOTT & WHITE
TX7240025OtherAETNA