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PED453304-196 Texas Children's Hospital (Terminated)
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Main Details
Name
Texas Children's Hospital
Subdivision Name
TEXAS CHILDREN'S HOSPITAL - WC Physical Therapy
Type
Children's Hospital
Rural
No
340B ID
PED453304-196
Medicare Provider Number
453304
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/13/2021
Participating Start Date
10/1/2021
Participating Approval Date
8/16/2021
Last Recertification Date
9/11/2022
Termination Date
Termination Reason
7/1/2023
Other
Contacts
Authorizing Official
Texas Children's Hospital
Weldon Gage, Executive Vice President/CFO
(832) 826-8084
Primary Contact
Texas Children's Hospital
Rosa I Lopez, Assistant Director , Pharmacy Financial Operations
(832) 824-1692
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
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