Provider Demographics
NPI:1891816559
Name:PEDIATRIC CARDIOLOGY OF MICHIANA, PC
Entity type:Organization
Organization Name:PEDIATRIC CARDIOLOGY OF MICHIANA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPECKHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-232-3325
Mailing Address - Street 1:707 N MICHIGAN ST
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1067
Mailing Address - Country:US
Mailing Address - Phone:574-232-3325
Mailing Address - Fax:574-232-3358
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:SUITE 316
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1067
Practice Address - Country:US
Practice Address - Phone:574-232-3325
Practice Address - Fax:574-232-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034696A2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100475760AMedicaid
4564274OtherAETNA
IN000000330797001OtherBLUE CROSS BLUE SHIELD IN
1761550OtherCIGNA
INB28499Medicare UPIN