1891011730 NPI number — ABC PEDIATRIACS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891011730 NPI number — ABC PEDIATRIACS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABC PEDIATRIACS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891011730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46308-1154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-662-3931
Provider Business Mailing Address Fax Number:
219-663-6359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6750 CALUMET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMMOND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46324-1646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-803-0311
Provider Business Practice Location Address Fax Number:
219-803-0217
Provider Enumeration Date:
04/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
AR MGR.
Authorized Official Telephone Number:
219-662-3931

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  01053391A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 305761883 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200978100A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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