Provider Demographics
NPI:1467589796
Name:INDIANA PEDIATRIC ASSOCIATES, PC
Entity Type:Organization
Organization Name:INDIANA PEDIATRIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:724-463-0476
Mailing Address - Street 1:2255 PHILADELPHIA STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-463-0476
Mailing Address - Fax:742-463-1196
Practice Address - Street 1:2255 PHILADELPHIA STREET
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-463-0476
Practice Address - Fax:742-463-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011670020001Medicaid