Provider Demographics
NPI:1942321773
Name:HIGHLAND PEDIATRICS & ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:HIGHLAND PEDIATRICS & ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELDOTT-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-654-4449
Mailing Address - Street 1:1250 MERCANTILE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1239
Mailing Address - Country:US
Mailing Address - Phone:618-654-4449
Mailing Address - Fax:618-654-3974
Practice Address - Street 1:1250 MERCANTILE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1239
Practice Address - Country:US
Practice Address - Phone:618-654-4449
Practice Address - Fax:618-654-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty