Provider Demographics
NPI:1629286794
Name:PEDIATRIC REHABILITATION OF INDIANA, INC
Entity Type:Organization
Organization Name:PEDIATRIC REHABILITATION OF INDIANA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CALDECOTT
Authorized Official - Last Name:DIETERICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-548-5270
Mailing Address - Street 1:5006 DEER PARK CIR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-6027
Mailing Address - Country:US
Mailing Address - Phone:361-548-5270
Mailing Address - Fax:
Practice Address - Street 1:3825 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4018
Practice Address - Country:US
Practice Address - Phone:361-548-5270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043182A2081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Single Specialty