Provider Demographics
NPI:1629267323
Name:NORTHEAST INDIANA PEDIATRIC SPECIALISTS, PC
Entity type:Organization
Organization Name:NORTHEAST INDIANA PEDIATRIC SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-483-0688
Mailing Address - Street 1:PO BOX 5191
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5191
Mailing Address - Country:US
Mailing Address - Phone:260-483-0688
Mailing Address - Fax:260-483-0798
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:STE # 102
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-483-0688
Practice Address - Fax:260-483-0798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004150A2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious DiseasesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN184500Medicare PIN