Provider Demographics
NPI:1114257052
Name:CHILDREN'S HEART CARE CLINIC LLC
Entity Type:Organization
Organization Name:CHILDREN'S HEART CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP AND CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-234-8354
Mailing Address - Street 1:14328 WATERWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-9455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14328 WATERWAY BLVD
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-9455
Practice Address - Country:US
Practice Address - Phone:646-234-8354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-26
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063650A2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty