Provider Demographics
NPI:1366569550
Name:CHILD AND ADOLESCENT CENTER, PA
Entity type:Organization
Organization Name:CHILD AND ADOLESCENT CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NURUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-644-1801
Mailing Address - Street 1:1150 N WATTERS RD # B
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5508
Mailing Address - Country:US
Mailing Address - Phone:214-644-1801
Mailing Address - Fax:214-644-1800
Practice Address - Street 1:1150 N WATTERS RD # B
Practice Address - Street 2:SUITE 108
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5508
Practice Address - Country:US
Practice Address - Phone:214-644-1801
Practice Address - Fax:214-644-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3690208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199445101Medicaid
TX8V2170OtherBCBS