1346529724 NPI number — CONNERY PEDIATRICS, LLC

Table of content: (NPI 1346529724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346529724 NPI number — CONNERY PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNERY PEDIATRICS, LLC
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:
6
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:
1346529724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1076
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:
46308-1076
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:
170 BRACKEN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46342-6789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-940-9605
Provider Business Practice Location Address Fax Number:
219-940-9606
Provider Enumeration Date:
08/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CONNERY
Authorized Official First Name:
MARC
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
219-942-7156

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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