Provider Demographics
NPI:1326193475
Name:MEDPEDS, LLC
Entity Type:Organization
Organization Name:MEDPEDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:JENISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-425-0300
Mailing Address - Street 1:3524 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-3320
Mailing Address - Country:US
Mailing Address - Phone:812-425-0300
Mailing Address - Fax:812-428-8400
Practice Address - Street 1:3524 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3320
Practice Address - Country:US
Practice Address - Phone:812-425-0300
Practice Address - Fax:812-428-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN193720AMedicare ID - Type UnspecifiedJAMES E. JENISON
IN193720BMedicare ID - Type UnspecifiedALBERT WALSH
IN193720Medicare ID - Type UnspecifiedMEDPEDS
INC25884Medicare UPIN
ING14899Medicare UPIN