Provider Demographics
NPI:1972583227
Name:FAYETTE COUNTY PEDIATRICS LLC
Entity Type:Organization
Organization Name:FAYETTE COUNTY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-825-4949
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-0779
Mailing Address - Country:US
Mailing Address - Phone:765-827-1903
Mailing Address - Fax:
Practice Address - Street 1:2025 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2921
Practice Address - Country:US
Practice Address - Phone:765-825-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty