MEDICARE: PEDIATRIC SPECIALTY PHYSICIANS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0203X	Pediatric Critical Care Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023198926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC SPECIALTY PHYSICIANS, PC

Provider Business Mailing Address
First Line	:	7429 INVERNESS COMMONS
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-3837
Country	:	US
Telephone Number	:	260-408-5801
Fax Number	:	888-949-8258

Provider Business Practice Location Address
First Line	:	7429 INVERNESS COMMONS
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-3837
Country	:	US
Telephone Number	:	260-408-5801
Fax Number	:	888-949-8258

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAYESH P PATEL
Credential	:	M.D.
Telephone Number	:	260-408-5801

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	08/25/2016

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