Provider Demographics
NPI:1588605349
Name:MIDWEST CHILD AND ADOLESCENT SPECIALTY GROUP, P.C.
Entity Type:Organization
Organization Name:MIDWEST CHILD AND ADOLESCENT SPECIALTY GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PABLITO
Authorized Official - Middle Name:S
Authorized Official - Last Name:DELA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-232-7337
Mailing Address - Street 1:1310 E DAVIS DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4034
Mailing Address - Country:US
Mailing Address - Phone:812-232-7337
Mailing Address - Fax:812-232-7338
Practice Address - Street 1:1310 E DAVIS DR
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4034
Practice Address - Country:US
Practice Address - Phone:812-232-7337
Practice Address - Fax:812-232-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059798A208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200506860AMedicaid
IN200506860AMedicaid