MEDICARE: PEDSTAT

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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1265519185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDSTAT

Provider Business Mailing Address
First Line	:	3919 W JEFFERSON BLVD
Second Line	:	SUITE 2
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6811
Country	:	US
Telephone Number	:	260-436-7722
Fax Number	:	260-459-0012

Provider Business Practice Location Address
First Line	:	3919 W JEFFERSON BLVD
Second Line	:	SUITE 2
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-6811
Country	:	US
Telephone Number	:	260-436-7722
Fax Number	:	260-459-0012

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GIRIDHAR RAO VEERULA
Credential	:	M.D.
Telephone Number	:	260-436-7722

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	09/07/2007

Similar Medicare Providers

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Practice Location Address:

3919 W JEFFERSON BLVD STE 2
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46804-6811

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Practice Location Address:

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Practice Location Address:

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1134542855 — JEFFERSON PEDIATRICS, PC
Practice Location Address:

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1598189979 — BRITTANY LEE SCHOENLE PA
Practice Location Address:

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Directions to “PEDSTAT ” Practice Location

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