Covered Entity Details

PED453302-26 CHILDREN'S MEDICAL CENTER DALLAS (Active) - information as of 4/23/2025 10:51:31 PM

Main Details

Name

CHILDREN'S MEDICAL CENTER DALLAS

Subdivision Name

Children's Health Specialty Center / Genetics / Metabolics

Type

Children's Hospital

Rural

340B ID

PED453302-26

Medicare Provider Number

453302

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/6/2015

Participating Start Date

10/1/2015

Participating Approval Date

7/22/2015

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Children's Health
Robert S. Fries, Chief Financial Officer
(214) 456-8414

Primary Contact

Children's Health
Chris Bradley Geiger, Director Business Operations, Ancillary Services
(214) 456-7437

Addresses

Street Address

2350 North Stemmons Freeway
F4200
Dallas, TX 75207

Billing Address

Children's Medical Center of Dallas
1935 Medical District Drive
Dallas, TX 75235

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TX	138910806,138910807	1194743013,1922428234
CO	95007662	1194743013,1922428234
FL	092726100	1194743013,1922428234
MS	06332782	1194743013,1922428234
OK	100701950C,100701950A	1194743013,1922428234
AR	107628105	1194743013,1922428234
LA	1734527,60116850	1194743013,1922428234
NM	A8416	1194743013,1922428234

Shipping Addresses

Shipping Address 1

Children's Medical Center of Dallas
1935 Medical District Drive
Dallas, TX 75235

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
PED453302-01	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S MEDICAL CENTER LEGACY	7601 PRESTON ROAD	PLANO	TX	Terminated
PED453302-02	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	DALLAS AMBULATORY CARE PAVILION	2350 STEMMONS FREEWAY	DALLAS	TX	Terminated
PED453302-03	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	DESOTO SPECIALTY CENTER	2828 DUKE OF GLOUCHESTER STREET	DESOTO	TX	Terminated
PED453302-04	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	IRVING SPECIALTY CENTER	400 I-635 E	IRVING	TX	Terminated
PED453302-05	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	MESQUITE SPECIALTY CENTER	1600 REPUBLIC PKWY	MESQUITE	TX	Terminated
PED453302-06	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHASE SPECIALTY CENTER	6300 HARRY HINES BOULEVARD	DALLAS	TX	Terminated
PED453302-07	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	PAVILION SURGERY CENTER	2350 North Stemmons Freeway	DALLAS	TX	Active
PED453302-08	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S AMBULATORY CARE PAVILION AT LEGACY	7601 PRESTON ROAD	PLANO	TX	Terminated
PED453302-09	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S AMBULATORY SURGERY CENTER AT SOUTHLAKE	470 E STATE HIGHWAY 114	SOUTHLAKE	TX	Terminated
PED453302-10	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Dallas Campus / Perioperative Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-11	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center at Cityville Physical Medicine & Rehabilitation/Outpatient Therapy	2222 Medical District Drive	Dallas	TX	Active
PED453302-12	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center at Cityville, Specialty Clinics	2222 Medical District Drive	Dallas	TX	Active
PED453302-13	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, Diagnostics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-14	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, MRI	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-15	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pavilion Imaging Center, Utrasound	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-16	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pulmonary Lab	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-17	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Sleep Disorders Center	2620 North Stemmons Freeway	Dallas	TX	Active
PED453302-18	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Adolescent & Young Adult Clinic	2350 North Stemmons Freeway	Dallas	TX	Terminated
PED453302-19	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Audiology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-20	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Cystic Fibrosis	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-21	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Dermatology	2350 North Stemmons Freeway	Dallas	TX	Terminated
PED453302-22	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / General Surgery	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-23	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pain Management	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-24	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Pulmonary	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-25	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Allergy/Immunology/Asthma Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-26	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Genetics / Metabolics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-27	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Diabetes/Endocrinology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-28	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Ears, Nose & Throat	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-29	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Eye Clinic/Ophthalmology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-30	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Rheumatology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-31	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Gastroenterology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-32	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Plastic & Craniofacial Surgery/Plastic Hand	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-33	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Orthopedics	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-34	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Neurology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-35	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / Special Procedures	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-36	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center / COACH (Center for Obesity and its Consequences in Health)	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-37	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1 / Psychiatry/ Psychology	1341 West Mockingbird Lane, Suite 1200E	Dallas	TX	Active
PED453302-38	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1; Center for Autism and Developmental Disabilities / Autism/Intensive Outpatient Autism	1341 West Mockingbird Lane, Suite 240W	Dallas	TX	Active
PED453302-39	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center Mockingbird 1; Psychiatry Day Treatment	1341 West Mockingbird Lane, Suite 500E	Dallas	TX	Active
PED453302-40	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER, Park Cities	8160 WALNUT HILL LN 106	DALLAS	TX	Active
PED453302-41	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Urology Clinic	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-42	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Adolescent & Gynecology	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-43	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, Dallas Campus / Foster Care Clinic (Rees-Jones Center for Foster Care Excellence)	2350 North Stemmons Freeway	Dallas	TX	Active
PED453302-44	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	Children's Health Specialty Center, South Rockwall - Urology Clinic	1005 West Ralph Hall Parkway	Rockwall	TX	Terminated
PED453302-45	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER - Epilepsy Clinic, Suite F5400	2350 N STEMMONS FWY	DALLAS	TX	Terminated
PED453302-46	Child	PED	CHILDREN'S MEDICAL CENTER DALLAS	CHILDREN'S HEALTH SPECIALTY CENTER - Neuropsychology Clinic, Suite F5000	2350 N STEMMONS FWY	DALLAS	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Fries, Robert S. Executive Vice President & Chief Financial Officer Children's Health 2144568414	Fries, Robert S. Chief Financial Officer Children's Health 2144568414	10/10/2024 8:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Geiger, Chris Bradley Director Business Operations, Pharmacy Services Children's Health 2144567437	Geiger, Chris Bradley Director Business Operations, Ancillary Services Children's Health 2144567437	10/9/2024 4:48 PM
Details	Last Recertification Date	Update	Recertification	8/17/2023 3:39:00 PM	8/13/2024 8:57:10 AM	8/13/2024 8:57 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 5:51:24 PM	8/17/2023 3:39:00 PM	8/17/2023 3:39 PM
Details	Last Recertification Date	Update	Recertification	8/20/2021 9:52:57 AM	8/29/2022 5:51:24 PM	8/29/2022 5:51 PM
Contacts	Authorizing Official	Update	Change Request	Radandt, Jeremiah President Corporate Services & CFO Children’s Health 2144562522	Fries, Robert S. Executive Vice President & Chief Financial Officer Children's Health 2144568414	11/16/2021 10:17 AM
Details	Last Recertification Date	Update	Recertification	9/2/2020 11:01:54 AM	8/20/2021 9:52:57 AM	8/20/2021 9:52 AM
Contacts	Authorizing Official	Update	Change Request	Berry, David T CHST President, System Clinical Operations Children's Health 2144562143	Radandt, Jeremiah President Corporate Services & CFO Children’s Health 2144562522	1/20/2021 10:56 AM
Details	Last Recertification Date	Update	Recertification	8/22/2019 3:28:20 PM	9/2/2020 11:01:54 AM	9/2/2020 11:01 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1194743013 ( )		8/12/2020 6:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1881830602 ( )		8/12/2020 6:22 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1588746002 ( )		8/12/2020 6:22 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		95007662	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		CO	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		092726100	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		FL	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		06332782	8/10/2020 10:11 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MS	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		TX	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		OK	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		AR	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		LA	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		NM	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		CO	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		FL	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1194743013	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		MS	8/10/2020 10:11 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1922428234	8/10/2020 10:11 AM
Medicaid Billing	NPI: State	Insert	Change Request		MS	8/10/2020 10:11 AM
Details	Last Recertification Date	Update	Recertification	8/21/2018 4:25:55 PM	8/22/2019 3:28:20 PM	8/22/2019 3:28 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/12/2019 4:30 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		138910806	8/12/2019 4:30 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		TX	8/12/2019 4:30 PM
Details	Last Recertification Date	Update	Recertification	11/25/2017 6:03:50 PM	8/21/2018 4:25:55 PM	8/21/2018 4:25 PM
Contacts	Primary Contact	Update	Change Request	Kromelis, Michelle Senior Director of Pharmacy Children's Health System of Texas 2144566203	Geiger, Chris Bradley Director Business Operations, Pharmacy Services Children's Health 2144567437	6/22/2018 7:04 PM
Details	Entity Name	Update	Recertification	CHILDRENS MEDICAL CENTER OF DALLAS	CHILDREN'S MEDICAL CENTER DALLAS	11/29/2017 9:57 PM
Details	Last Recertification Date	Update	Recertification	8/16/2016 12:00:00 AM	11/25/2017 6:03:50 PM	11/25/2017 6:03 PM
Contacts	Authorizing Official	Update		Berry, David CHST President, System Clinical Operations 2144562143	Berry, David T CHST President, System Clinical Operations Children's Health 2144562143	10/10/2017 9:42 AM
Contacts	Primary Contact	Update		Kromelis, Michelle Senior Director of Pharmacy 2144566203	Kromelis, Michelle Senior Director of Pharmacy Children's Health System of Texas 2144566203	10/9/2017 2:55 PM
Contacts	Authorizing Official	Insert			Berry, David CHST President, System Clinical Operations 2144562143	8/9/2017 3:27 PM
Contacts	Primary Contact	Insert			Kromelis, Michelle Senior Director of Pharmacy 2144566203	5/10/2017 6:31 AM
Contacts	Signed By	Insert			Eager, David SVP Finance & CFO 2144567890	5/10/2017 6:31 AM
Addresses	Main Address	Insert			2350 North Stemmons Freeway F4200 Dallas, TX 75207	4/25/2017 1:24 PM
Addresses	Billing Address	Insert			Children's Medical Center of Dallas 1935 Medical District Drive Dallas, TX 75235	4/25/2017 1:24 PM
Addresses	Shipping Address	Insert			Children's Medical Center of Dallas 1935 Medical District Drive Dallas, TX 75235	4/25/2017 1:24 PM
Medicaid Billing	Medicaid: Number	Update		13890807	138910807	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Number	Insert			100701950A	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: State	Insert			OK	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Number	Insert			107628105	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: State	Insert			AR	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Number	Insert			1734527	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: State	Insert			LA	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Number	Insert			60116850	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: State	Insert			LA	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: Number	Insert			A8416	2/3/2017 9:46 AM
Medicaid Billing	Medicaid: State	Insert			NM	2/3/2017 9:46 AM
Details	Last Recertification Date	Update			8/16/2016 12:00:00 AM	8/16/2016 7:18 AM
Dates	Participating Approval Date	Update			7/22/2015 12:00:00 AM	7/22/2015 3:38 PM
Details	State	Update		Pending	Active	7/22/2015 3:38 PM
Dates	Start Date	Update			10/1/2015 12:00:00 AM	7/22/2015 3:38 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_52281	PED453302-26	7/22/2015 1:06 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_52281	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: Number	Insert			13890807	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: State	Insert			TX	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: Number	Insert			100701950C	7/6/2015 5:25 PM
Medicaid Billing	Medicaid: State	Insert			OK	7/6/2015 5:25 PM
Medicaid Billing	NPI: Number	Insert			1194743013	7/6/2015 5:25 PM
Medicaid Billing	NPI: Number	Insert			1881830602	7/6/2015 5:25 PM
Medicaid Billing	NPI: Number	Insert			1588746002	7/6/2015 5:25 PM
Details	Last Recertification Date	Insert				7/6/2015 5:25 PM
Details	Grant Number	Insert				7/6/2015 5:25 PM
Details	340B ID	Insert				7/6/2015 5:25 PM
Details	Is Authorizing Official EHB Data	Insert				7/6/2015 5:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert				7/6/2015 5:25 PM
Details	Medicare Provider Number	Insert			453302	7/6/2015 5:25 PM
Details	Entity Name	Insert			CHILDRENS MEDICAL CENTER OF DALLAS	7/6/2015 5:25 PM
Details	Program Code	Insert			PED	7/6/2015 5:25 PM
Details	Entity Subname	Insert			Children's Health Specialty Center / Genetics / Metabolics	7/6/2015 5:25 PM
Dates	Participating Approval Date	Insert				7/6/2015 5:25 PM
Details	State	Insert			Pending	7/6/2015 5:25 PM
Dates	Registration Date	Insert			7/6/2015 12:00:00 AM	7/6/2015 5:25 PM
Dates	Signed By Date	Insert			7/6/2015 12:00:00 AM	7/6/2015 5:25 PM
Dates	Start Date	Insert				7/6/2015 5:25 PM
Terminations	Termination Comments	Insert				7/6/2015 5:25 PM
Terminations	Termination Date	Insert				7/6/2015 5:25 PM
Terminations	Termination Effective Date	Insert				7/6/2015 5:25 PM
Terminations	Termination Reason	Insert				7/6/2015 5:25 PM