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PED453302-01 CHILDREN'S MEDICAL CENTER DALLAS (Terminated)
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Main Details
Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
CHILDREN'S MEDICAL CENTER LEGACY
Type
Children's Hospital
Rural
No
340B ID
PED453302-01
Medicare Provider Number
453302
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/25/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/25/2010
Last Recertification Date
8/7/2014
Termination Date
Termination Reason
7/1/2015
Site closure
Contacts
Authorizing Official
Children's Health
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Primary Contact
Children's Health System of Texas
Michelle Kromelis, Senior Director of Pharmacy
(214) 456-6203
Addresses
Street Address
7601 PRESTON ROAD
PLANO, TX 75024
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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4/7/2010- UPDATED SUB-DIV. NAME (WAS CHILDREN'S AMBULATORY CARE PAVILION AT LEGACY);
04/07/2010
June 2025
June 2025
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