Provider Demographics
NPI:1790880292
Name:PEDIATRIC SURGICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:PEDIATRIC SURGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-948-3525
Mailing Address - Street 1:705 RILEY HOSPITAL DR
Mailing Address - Street 2:STE 2500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5109
Mailing Address - Country:US
Mailing Address - Phone:317-274-4681
Mailing Address - Fax:317-274-4491
Practice Address - Street 1:250 N SHADELAND AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4959
Practice Address - Country:US
Practice Address - Phone:877-668-5621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200349840Medicaid
185720Medicare ID - Type Unspecified