Provider Demographics
NPI:1669674461
Name:CLOWN PEDIATRICS
Entity type:Organization
Organization Name:CLOWN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:ROSCOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-881-8737
Mailing Address - Street 1:401 CAMBY CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-4085
Mailing Address - Country:US
Mailing Address - Phone:317-881-8737
Mailing Address - Fax:317-881-8735
Practice Address - Street 1:401 CAMBY CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4085
Practice Address - Country:US
Practice Address - Phone:317-881-8737
Practice Address - Fax:317-881-8735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1057187 A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200479420 AMedicaid