Provider Demographics
NPI:1760486393
Name:LINCOLN PEDIC CLINIC, INC.
Entity Type:Organization
Organization Name:LINCOLN PEDIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:ALYCE
Authorized Official - Last Name:PAUNWAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-637-8414
Mailing Address - Street 1:12311 AUTUMN BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9111
Mailing Address - Country:US
Mailing Address - Phone:260-637-8414
Mailing Address - Fax:260-637-8152
Practice Address - Street 1:12311 AUTUMN BREEZE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9111
Practice Address - Country:US
Practice Address - Phone:260-637-8414
Practice Address - Fax:260-637-8152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000776A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000235683OtherANTHEM BLUE CROSS
IN100210380AMedicaid
INC31367OtherPALMETTO GBA
IN000000235683OtherANTHEM BLUE CROSS