Provider Demographics
NPI:1891011730
Name:ABC PEDIATRIACS, PC
Entity Type:Organization
Organization Name:ABC PEDIATRIACS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AR MGR.
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-662-3931
Mailing Address - Street 1:PO BOX 1154
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-1154
Mailing Address - Country:US
Mailing Address - Phone:219-662-3931
Mailing Address - Fax:219-663-6359
Practice Address - Street 1:6750 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46324-1646
Practice Address - Country:US
Practice Address - Phone:219-803-0311
Practice Address - Fax:219-803-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-16
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053391A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL305761883Medicaid
IN200978100AMedicaid
IL305761883Medicaid