Provider Demographics
NPI:1578661278
Name:PEDIATRIC CARE IRRV TRUST
Entity Type:Organization
Organization Name:PEDIATRIC CARE IRRV TRUST
Other - Org Name:PEDIATRICCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:785-354-9591
Mailing Address - Street 1:4100 SW 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-4333
Mailing Address - Country:US
Mailing Address - Phone:785-273-8224
Mailing Address - Fax:785-273-0524
Practice Address - Street 1:4100 SW 15TH ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-4333
Practice Address - Country:US
Practice Address - Phone:785-273-8224
Practice Address - Fax:785-273-0524
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STORMONT-VAIL HEALTHCARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2129OtherMEDICARE PTAN
KS100278070AMedicaid
110292Medicare ID - Type Unspecified