Provider Demographics
NPI:1376534685
Name:TELL CITY PEDIATRICS
Entity Type:Organization
Organization Name:TELL CITY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:STUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-547-7011
Mailing Address - Street 1:109 US HIGHWAY 66 E
Mailing Address - Street 2:
Mailing Address - City:TELL CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47586-2755
Mailing Address - Country:US
Mailing Address - Phone:812-547-3447
Mailing Address - Fax:812-547-9543
Practice Address - Street 1:109 US HIGHWAY 66 E
Practice Address - Street 2:
Practice Address - City:TELL CITY
Practice Address - State:IN
Practice Address - Zip Code:47586-2755
Practice Address - Country:US
Practice Address - Phone:812-547-3447
Practice Address - Fax:812-547-9543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERRY COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-04
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000359519OtherANTHEM
KY65943706Medicaid
IN15D1038972OtherCLIA
IN200398420AMedicaid