Provider Demographics
NPI:1225169196
Name:PEDIATRIC PULMONARY & CRITICAL CARE, PC
Entity Type:Organization
Organization Name:PEDIATRIC PULMONARY & CRITICAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRASHEKHAR
Authorized Official - Middle Name:CHOWDARY
Authorized Official - Last Name:YALAMANCHALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-435-7800
Mailing Address - Street 1:PMB 218 10214 CHESTNUT PLAZA DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8970
Mailing Address - Country:US
Mailing Address - Phone:260-435-7800
Mailing Address - Fax:260-435-7007
Practice Address - Street 1:7910 WEST JEFFERSON BLVD.
Practice Address - Street 2:STE 205
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-435-7800
Practice Address - Fax:260-435-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 2080P0203X, 2080P0214X
IN01049779A2080P0203X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200246880Medicaid
IN200231310Medicaid
IN200500220Medicaid