Provider Demographics
NPI:1972823839
Name:IYER PEDIATRIC CARE CLINIC LLC
Entity Type:Organization
Organization Name:IYER PEDIATRIC CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAJARAMAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:IYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-791-3613
Mailing Address - Street 1:10006 TANGLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4320 FIR ST
Practice Address - Street 2:SUITE 208
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3052
Practice Address - Country:US
Practice Address - Phone:219-398-9265
Practice Address - Fax:219-398-9370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055306A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200984240AMedicaid