Provider Demographics
NPI:1386674513
Name:PEDIATRIC & INTERNAL MEDICINE CENTER
Entity Type:Organization
Organization Name:PEDIATRIC & INTERNAL MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-966-5527
Mailing Address - Street 1:1434 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1947
Mailing Address - Country:US
Mailing Address - Phone:765-966-5527
Mailing Address - Fax:765-966-5527
Practice Address - Street 1:1434 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1947
Practice Address - Country:US
Practice Address - Phone:765-966-5527
Practice Address - Fax:765-966-5527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000450A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CI9605OtherMEDICARE RR
OH0121808Medicaid
IN100255760AMedicaid
15D0360467OtherCLIA#
15D0360467OtherCLIA#