Provider Demographics
NPI:1689773681
Name:GREENWOOD PEDIATRICS PC
Entity Type:Organization
Organization Name:GREENWOOD PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:G
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-887-6060
Mailing Address - Street 1:1030 E COUNTY LINE RD
Mailing Address - Street 2:SUITE B2
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2932
Mailing Address - Country:US
Mailing Address - Phone:317-887-6060
Mailing Address - Fax:317-859-5946
Practice Address - Street 1:1030 E COUNTY LINE RD
Practice Address - Street 2:SUITE B2
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2932
Practice Address - Country:US
Practice Address - Phone:317-887-6060
Practice Address - Fax:317-859-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100193950AMedicaid