Provider Demographics
NPI:1457396541
Name:UNIVERSITY PEDIATRIC ASSOCIATES, INC.
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRIC ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY - TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANELINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-777-6435
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RR 127
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-777-6435
Practice Address - Fax:317-777-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510084Medicaid
IN200026880Medicaid
VT1011388Medicaid
WV3810016815Medicaid
IN100382090Medicaid
IN200026890Medicaid
FL097150200Medicaid
AL144666Medicaid
IN200026880Medicaid