Provider Demographics
NPI:1669553186
Name:BARD AND DIDRIKSEN PEDIATRICS, P.C.
Entity type:Organization
Organization Name:BARD AND DIDRIKSEN PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SUDHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-692-1212
Mailing Address - Street 1:2160 SO. IL. RT. 157
Mailing Address - Street 2:SUITE B
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-692-1212
Mailing Address - Fax:618-692-4875
Practice Address - Street 1:2160 SO IL RT 157
Practice Address - Street 2:SUITE B
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-692-1212
Practice Address - Fax:618-692-4875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty