Covered Entity Details

PED453304-166 Texas Children's Hospital (Active) - information as of 4/29/2025 11:54:01 PM

Main Details

Name

Texas Children's Hospital

Subdivision Name

TEXAS CHILDREN'S HOSPITAL - WC RESPIRATORY CARE

Type

Children's Hospital

Rural

340B ID

PED453304-166

Medicare Provider Number

453304

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

7/11/2019

Participating Start Date

10/1/2019

Participating Approval Date

7/24/2019

Last Recertification Date

9/8/2024

Contacts

Authorizing Official

Texas Children's Hospital
Weldon Gage, Executive Vice President/CFO
(832) 826-8084

Primary Contact

Texas Children's Hospital
Maronica V Waldrup, Financial Analyst
(832) 824-6532

Addresses

Street Address

18200 KATY FWY
TCH WEST CAMPUS
HOUSTON, TX 77094-1285

Billing Address
Same as Street Address

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	251034,139135109	1891971222,1477643690,1184078743

Shipping Addresses

Same as Street Address

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
PED453304-01	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Pedi Radiology Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-02	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Allergy and Immunology	18200 Katy Freeway	Houston	TX	Active
PED453304-03	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Neurology Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-04	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Cardiology Clinic & ECG	18200 Katy Freeway	Houston	TX	Active
PED453304-05	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Diabetes/Endocrine Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-06	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Urology Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-07	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Pedi Surgery	18200 Katy Freeway	Houston	TX	Active
PED453304-08	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Orthopedic Surgery	18200 Katy Freeway	Houston	TX	Active
PED453304-09	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Otolaryngology Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-10	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Ophtalmology Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-100	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC ORTHO/SPORTS MED RADIOLOGY	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-101	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO AUDIOLOGY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-102	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Audiology	6330 WEST LOOP SOUTH STE. 300	BELLAIRE	TX	Terminated
PED453304-103	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC DERMATOLOGY CLINIC	18200 KATY FWY	HOUSTON	TX	Active
PED453304-104	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO CARDIOLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-105	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ORTHOPEDIC SURGERY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-106	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO GENERAL LABORATORY	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-107	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO OCCUPATIONAL THERAPY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-108	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC PLASTIC SURGERY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-109	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO RHEUMATOLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-11	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Nutrition/GI Outpatient	18200 Katy Freeway	Houston	TX	Active
PED453304-110	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ALLERGY & IMMUNOLOGY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-111	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC ANESTHESIA	18200 KATY FWY	HOUSTON	TX	Active
PED453304-112	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO INFUSION CENTER	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-113	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PEDIATRIC SURGERY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-114	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC VASCULAR ACCESS TEAM	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-115	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC HAND CLINIC	18200 KATY FWY	HOUSTON	TX	Active
PED453304-116	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ORTHO/SPORTS MED PT	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-117	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PHYSICAL THERAPY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-118	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ULTRASOUND	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-119	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO CARDIOLOGY DIAGNOSTICS	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-12	Child	PED	Texas Children's Hospital	Texas Children's Hospital WC Pulmonary Clinic	18200 Katy Freeway	Houston	TX	Active
PED453304-120	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO OPERATING ROOMS	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-121	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Audiology	5514 ATASCOCITA RD. STE 190	HUMBLE	TX	Terminated
PED453304-122	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PLASTIC SURGERY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-123	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO NPHYSIOLOGY EEG	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-124	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO UROLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-125	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC SPECIAL PROCEDURES SUITE	18200 KATY FWY	HOUSTON	TX	Active
PED453304-126	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO TCCC OUTPATIENT CENTER	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-127	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PULMONARY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-128	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Otolaryngology	5514 ATASCOCITA RD. STE 190	HUMBLE	TX	Active
PED453304-129	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ANESTHESIA	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-13	Child	PED	Texas Children's Hospital	Texas Children's Hospital West Campus Infusion Center	18200 Katy Freeway	Houston	TX	Active
PED453304-130	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO HR NEO FOLLOWUP CLINIC	17198 ST. LUKES WAY, MAC BLDG #1 STE300	THE WOODLANDS	TX	Active
PED453304-131	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC EEG SHORT	18200 KATY FWY	HOUSTON	TX	Active
PED453304-132	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PEDI RADIOLOGY - CLINIC	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-133	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PEDI RADIOLOGY-MAIN SUITE	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-134	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO OTOLARYNGOLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-135	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Orthopedics	6330 WEST LOOP SOUTH STE. 300	BELLAIRE	TX	Active
PED453304-136	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Sleep Lab	18200 KATY FWY	HOUSTON	TX	Active
PED453304-137	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC RETROVIROLOGY TRAVEL MED	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-138	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC BRACHIAL PLEXUS CLINIC	18200 KATY FWY	HOUSTON	TX	Active
PED453304-139	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO INFECTIOUS DISEASE	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-14	Child	PED	Texas Children's Hospital	Texas Children's Hospital West Campus TCCC Outpatient Center	18200 Katy Freeway	Houston	TX	Active
PED453304-140	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PACU	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-141	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Otolaryngology	6330 WEST LOOP SOUTH STE. 300	BELLAIRE	TX	Active
PED453304-142	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC PACU	18200 KATY FWY	HOUSTON	TX	Active
PED453304-143	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO GAIT LAB	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-144	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO CT	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-145	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC FORMULA/ MILK BANK	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-146	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO DIABETES/ENDOCRINE CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-147	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO SPEECH THERAPY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-148	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO OPHTHALMOLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-149	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC OPERATING ROOMS	18200 KATY FWY	HOUSTON	TX	Active
PED453304-15	Child	PED	Texas Children's Hospital	Woodlands Health Center / Neurology	17350 St Lukes Way	The Woodlands	TX	Terminated
PED453304-150	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PEDIATRIC RADIOLOGY PACU	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-151	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO NEUROLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-152	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO Pulmonary Diagnostic Lab	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-153	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC CARDIOLOGY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-154	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Infectious Disease	18200 KATY FWY	HOUSTON	TX	Active
PED453304-155	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - MFM The Woodlands Clinic	17183 I-45 SOUTH STE 430	THE WOODLANDS	TX	Active
PED453304-156	Child	PED	Texas Children's Hospital	MFM Baytown Clinic - MFM Baytown	2610 N Alexander Dr	Baytown	TX	Active
PED453304-157	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - AUTISM CENTER	8080 N STADIUM DR	HOUSTON	TX	Active
PED453304-158	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - MFM West Houston Clinic	18400 KATY FWY, STE 540	HOUSTON	TX	Active
PED453304-159	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC RENAL	18200 KATY FWY	HOUSTON	TX	Active
PED453304-16	Child	PED	Texas Children's Hospital	Woodlands Health Center / Psychology	17198 St Lukes Way #300	The Woodlands	TX	Active
PED453304-160	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Sugar Land HC - Therapy Dept	15400 SOUTHWEST FWY, STE 200	SUGAR LAND	TX	Active
PED453304-161	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO Emergency Center	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-162	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC GENERAL LABORATORY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-163	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Psychology	18200 KATY FWY	HOUSTON	TX	Active
PED453304-164	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Kingwood Outpatient Therapy Center	19298 W LAKE HOUSTON PKWY, STE 220	HUMBLE	TX	Terminated
PED453304-165	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Clear Lake HC -Therapy Dept	940 CLEAR LAKE CITY BLVD, STE 200	WEBSTER	TX	Terminated
PED453304-166	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC RESPIRATORY CARE	18200 KATY FWY	HOUSTON	TX	Active
PED453304-167	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC INTERVENTIONAL RADIOLOGY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-168	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC MRI	18200 KATY FWY	HOUSTON	TX	Active
PED453304-169	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC DI NURSING	18200 KATY FWY	HOUSTON	TX	Active
PED453304-17	Child	PED	Texas Children's Hospital	Woodlands Health Center / Psychiatry	17198 St Lukes Way #300	The Woodlands	TX	Active
PED453304-170	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Complex Care	18200 KATY FWY	HOUSTON	TX	Active
PED453304-172	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Bellaire Outpatient Therapy Center	6330 WEST LOOP SOUTH STE 300	BELLAIRE	TX	Terminated
PED453304-173	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC ORTHO/SPORT MED RADIOLOGY	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-174	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - Cy-Fair HC Therapy Dept	11777 FM 1960 RD W	HOUSTON	TX	Terminated
PED453304-175	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - MFM Willowbrook Clinic	13215 DOTSON RD, STE 360	HOUSTON	TX	Active
PED453304-176	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PHYSICAL THERAPY	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-177	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC CT	18200 KATY FWY	HOUSTON	TX	Active
PED453304-178	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC MULTISPECIALTY CLINIC	18200 KATY FWY	HOUSTON	TX	Active
PED453304-18	Child	PED	Texas Children's Hospital	Woodlands Health Center / Opthalmology	17198 St Lukes Way #300	The Woodlands	TX	Active
PED453304-180	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - MFM Sugar Land Clinic	16605 SOUTHWEST FWY, STE 500	SUGAR LAND	TX	Active
PED453304-181	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - MFM The Methodist Hospital	6550 FANNIN ST, STE 901	HOUSTON	TX	Active
PED453304-182	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC ORTHO/SPORTS MED PT	18200 KATY FWY	HOUSTON	TX	Active
PED453304-183	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC SPEECH,LANG & LEARNING	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-184	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC OCCUPATIONAL THERAPY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-185	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC AUDIOLOGY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-187	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Emergency Center	18200 KATY FWY	HOUSTON	TX	Active
PED453304-188	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Pulmonary Diagnostic Lab	18200 KATY FWY	HOUSTON	TX	Active
PED453304-189	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - CL Rheumatology	940 CLEAR LAKE CITY BLVD, STE 200	WEBSTER	TX	Active
PED453304-19	Child	PED	Texas Children's Hospital	Woodlands Health Center / Developmental Pediatrics	17198 St. Lukes Way #300	The Woodlands	TX	Active
PED453304-190	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Sleep Clinic	18200 KATY FWY	HOUSTON	TX	Active
PED453304-191	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Developmental Pediatrics	18200 KATY FWY	HOUSTON	TX	Active
PED453304-192	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Psychiatry	18200 KATY FWY	HOUSTON	TX	Active
PED453304-193	Child	PED	Texas Children's Hospital	Texas Children's Hospital The Woodlands - Women's Clinic -The Woodlands	17350 St. Luke's Way	The Woodlands	TX	Terminated
PED453304-194	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO Adolescent Medicine	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-195	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO Renal Clinic	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-196	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC Physical Therapy	18200 KATY FWY	HOUSTON	TX	Terminated
PED453304-20	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Urology	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-21	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Ultrasound	940 Clear Lake City Blvd	Webster	TX	Terminated
PED453304-22	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Therapies	940 Clear Lake City Blvd	Webster	TX	Terminated
PED453304-23	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Pediatric Surgery	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-24	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Otolaryngology (ENT)	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-25	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Orthopedics	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-26	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Neurology	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-27	Child	PED	Texas Children's Hospital	Clear Lake Health Center / GI and Nutrition	940 Clear Lake City Blvd	Webster	TX	Terminated
PED453304-28	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Diagnostic Imaging	940 Clear Lake City Blvd	Webster	TX	Terminated
PED453304-29	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Diabetes / Endocrinology	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-30	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Cardiology	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-31	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Audiology	940 Clear Lake City Blvd	Webster	TX	Terminated
PED453304-32	Child	PED	Texas Children's Hospital	Clear Lake Health Center / Asthma/Pulmonary	940 Clear Lake City Blvd	Webster	TX	Active
PED453304-33	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Urology	11777 FM 1960	Houston	TX	Terminated
PED453304-34	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Therapy- Speech, Occupational and Physical /Sports	11777 FM 1960	Houston	TX	Active
PED453304-35	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Sports Medicine	11777 FM 1960	Houston	TX	Active
PED453304-36	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Rheumatology	11777 FM 1960	Houston	TX	Active
PED453304-37	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Renal	11777 FM 1960	Houston	TX	Terminated
PED453304-38	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Plastic Surgery	11777 FM 1960	Houston	TX	Active
PED453304-39	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Physical Medicine and Rehabilitation	11777 FM 1960	Houston	TX	Active
PED453304-40	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Pediatric Surgery	11777 FM 1960	Houston	TX	Active
PED453304-41	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / GI and Nutrition	11777 FM 1960	Houston	TX	Active
PED453304-42	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Otolaryngology (ENT)	11777 FM 1960	Houston	TX	Active
PED453304-43	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Orthopedics	11777 FM 1960	Houston	TX	Active
PED453304-44	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Ophthalmology	11777 FM 1960	Houston	TX	Active
PED453304-45	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Neurophysiology	11777 FM 1960	Houston	TX	Terminated
PED453304-46	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Neurology	11777 FM 1960	Houston	TX	Active
PED453304-47	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Diagnostic Imaging	11777 FM 1960	Houston	TX	Terminated
PED453304-48	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Diabetes/ Endocrinology	11777 FM 1960	Houston	TX	Active
PED453304-49	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Cardiology	11777 FM 1960	Houston	TX	Active
PED453304-50	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Audiology	11777 FM 1960	Houston	TX	Terminated
PED453304-51	Child	PED	Texas Children's Hospital	Cy-Fair Health Center / Asthma/Pulmonary	11777 FM 1960	Houston	TX	Active
PED453304-52	Child	PED	Texas Children's Hospital	Kingwood Health Center / Urology	19298 W. Lake Houston Pkwy	Humble	TX	Active
PED453304-53	Child	PED	Texas Children's Hospital	Kingwood Health Center / Sports Medicine	19298 W. Lake Houston Pkwy	Humble	TX	Terminated
PED453304-54	Child	PED	Texas Children's Hospital	Kingwood Health Center / Pulmonology	19298 W. Lake Houston Pkwy	Humble	TX	Active
PED453304-55	Child	PED	Texas Children's Hospital	Kingwood Health Center / Plastic Surgery	19298 W. Lake Houston Pkwy	Humble	TX	Terminated
PED453304-56	Child	PED	Texas Children's Hospital	Kingwood Health Center / Pediatric Surgery	19298 W. Lake Houston Pkwy	Humble	TX	Active
PED453304-57	Child	PED	Texas Children's Hospital	Kingwood Health Center / Orthopedics	19298 W. Lake Houston Pkwy	Humble	TX	Active
PED453304-58	Child	PED	Texas Children's Hospital	Kingwood Health Center / Cardiology	19298 W. Lake Houston Pkwy	Humble	TX	Active
PED453304-59	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Psychology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-60	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Psychiatry	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-61	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Urology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-62	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Rheumatology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-63	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Physical Medicine and Rehabilitation	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-64	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Pulmonary	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-65	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Pediatric Surgery	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-66	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Plastic Surgery	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-67	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Otolaryngology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-68	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Orthopedics	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-69	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Neurology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-70	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Gynecology-Pediatric and adolescent	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-71	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Gastroenterology and Nutrition	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-72	Child	PED	Texas Children's Hospital	Sugarland Health CLI / EEG	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-73	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Diagnostic Imaging	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-74	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Diabetes and Endocrine	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-75	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Developmental Pediatrics	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-76	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Dermatology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-77	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Cardiology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-78	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Audiology	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-79	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Allergy and Immunology	15400 Southwest Fwy #200	Sugar Land	TX	Active
PED453304-80	Child	PED	Texas Children's Hospital	Sugarland Health CLI / Adolescent Sports Medicine	15400 Southwest Fwy #200	Sugar Land	TX	Terminated
PED453304-81	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO SPECIAL PROCEDURES SUITE	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-82	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO SLEEP LAB	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-83	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO MRI	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-84	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO PHY MED/REHAB CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-85	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO GENETICS	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-86	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC PEDI RADIOLOGY-MAIN SUITE	18200 KATY FWY	HOUSTON	TX	Active
PED453304-87	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC PRIMARY SPORTS CARE	18200 KATY FWY	HOUSTON	TX	Active
PED453304-88	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO RESPIRATORY CARE	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-89	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO SPORTS MED CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-90	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO NUTRITION/GI OUTPATIENT	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-91	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC RHEUMATOLOGY	18200 KATY FWY	HOUSTON	TX	Active
PED453304-92	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO INPATIENT THERAPY	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-93	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO BEHAVIORAL (DEV,BEH, PSY)	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Terminated
PED453304-94	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO MILK BANK/LACTATION SPPT	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-95	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO DERMATOLOGY CLINIC	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-96	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO VASCULAR ACCESS TEAM	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Terminated
PED453304-97	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO RADIOLOGY INTERVENTIONAL	17600 INTERSTATE 45 SOUTH	THE WOODLANDS	TX	Active
PED453304-98	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WOO ADOL/PEDI GYNECOLOGY	17580 INTERSTATE 45 S	THE WOODLANDS	TX	Active
PED453304-99	Child	PED	Texas Children's Hospital	TEXAS CHILDREN'S HOSPITAL - WC ULTRASOUND	18200 KATY FWY	HOUSTON	TX	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	9/4/2023 10:49:26 PM	9/8/2024 9:53:43 PM	9/8/2024 9:53 PM
Contacts	Primary Contact	Update	Profile Change Request	Waldrup, Maronica V 340B Pharmacy Supervisor Texas Children's Hospital 8328246532	Waldrup, Maronica V Financial Analyst Texas Children's Hospital 8328246532	9/4/2024 5:51 PM
Details	Last Recertification Date	Update	Recertification	9/10/2022 8:21:31 PM	9/4/2023 10:49:26 PM	9/4/2023 10:49 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 9:08:17 PM	9/10/2022 8:21:31 PM	9/10/2022 8:21 PM
Details	Last Recertification Date	Update	Recertification	8/24/2020 2:43:06 PM	8/23/2021 9:08:17 PM	8/23/2021 9:08 PM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/24/2020 2:43 PM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/24/2020 2:43 PM
Medicaid Billing	NPI: State	Update	Recertification		TX	8/24/2020 2:43 PM
Details	Last Recertification Date	Update	Recertification		8/24/2020 2:43:06 PM	8/24/2020 2:43 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1184078743	7/25/2020 3:58 PM
Details	State	Update		Approved	Active	10/1/2019 12:04 AM
Contacts	Signed By	Insert	New Registration		Gage, Weldon Executive Vice President/CFO Texas Children's Hospital 8328268084	7/24/2019 1:22 PM
Details	340B ID	Update	New Registration		PED453304-166	7/24/2019 1:22 PM
Details	Entity Name	Update	New Registration	TEXAS CHILDRENS HOSPITAL	Texas Children's Hospital	7/24/2019 1:22 PM
Details	Entity Subname	Update	New Registration	TEXAS CHILDREN'S HOSPITAL	TEXAS CHILDREN'S HOSPITAL - WC RESPIRATORY CARE	7/24/2019 1:22 PM
Dates	Participating Approval Date	Update	New Registration		7/24/2019 1:22:37 PM	7/24/2019 1:22 PM
Details	State	Update	New Registration	Pending	Approved	7/24/2019 1:22 PM
Dates	Signed By Date	Update	New Registration		7/12/2019 12:28:57 PM	7/24/2019 1:22 PM
Dates	Start Date	Update	New Registration		10/1/2019 12:00:00 AM	7/24/2019 1:22 PM
Addresses	Main Address	Insert	New Registration		18200 KATY FWY TCH WEST CAMPUS HOUSTON, TX 77094-1285	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		251034	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		139135109	7/11/2019 3:04 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		TX	7/11/2019 3:04 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1891971222	7/11/2019 3:04 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1477643690	7/11/2019 3:04 PM
Contacts	Authorizing Official	Insert	New Registration		Gage, Weldon Executive Vice President/CFO Texas Children's Hospital 8328268084	7/11/2019 3:04 PM
Contacts	Primary Contact	Insert	New Registration		Waldrup, Maronica V 340B Pharmacy Supervisor Texas Children's Hospital 8328246532	7/11/2019 3:04 PM
Details	Last Recertification Date	Insert	New Registration			7/11/2019 3:04 PM
Details	Grant Number	Insert	New Registration			7/11/2019 3:04 PM
Details	340B ID	Insert	New Registration			7/11/2019 3:04 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			7/11/2019 3:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			7/11/2019 3:04 PM
Details	Medicare Provider Number	Insert	New Registration		453304	7/11/2019 3:04 PM
Details	Entity Name	Insert	New Registration		TEXAS CHILDRENS HOSPITAL	7/11/2019 3:04 PM
Details	Program Code	Insert	New Registration		PED	7/11/2019 3:04 PM
Details	Entity Subname	Insert	New Registration		TEXAS CHILDREN'S HOSPITAL	7/11/2019 3:04 PM
Dates	Participating Approval Date	Insert	New Registration			7/11/2019 3:04 PM
Details	State	Insert	New Registration		Pending	7/11/2019 3:04 PM
Dates	Registration Date	Insert	New Registration		7/11/2019 3:04:04 PM	7/11/2019 3:04 PM
Dates	Signed By Date	Insert	New Registration			7/11/2019 3:04 PM
Dates	Start Date	Insert	New Registration			7/11/2019 3:04 PM
Terminations	Termination Comments	Insert	New Registration			7/11/2019 3:04 PM
Terminations	Termination Date	Insert	New Registration			7/11/2019 3:04 PM
Terminations	Termination Effective Date	Insert	New Registration			7/11/2019 3:04 PM
Terminations	Termination Reason	Insert	New Registration			7/11/2019 3:04 PM