Provider Demographics
NPI:1801286075
Name:PEDINEURO LLC
Entity type:Organization
Organization Name:PEDINEURO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:512-917-0642
Mailing Address - Street 1:3403 NEEDLES DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-1410
Mailing Address - Country:US
Mailing Address - Phone:412-920-4000
Mailing Address - Fax:
Practice Address - Street 1:3403 NEEDLES DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-1410
Practice Address - Country:US
Practice Address - Phone:412-920-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG24052084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB23848Medicare UPIN