Provider Demographics
NPI:1174979348
Name:EMERALD PEDIATRIC CLINIC PA
Entity type:Organization
Organization Name:EMERALD PEDIATRIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-444-7726
Mailing Address - Street 1:11511 VETERANS MEMORIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77067
Mailing Address - Country:US
Mailing Address - Phone:281-444-7726
Mailing Address - Fax:
Practice Address - Street 1:11511 VETERANS MEMORIAL DR STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77067-2613
Practice Address - Country:US
Practice Address - Phone:281-444-7726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130641364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP130641Medicaid