Healthcare Provider Details

I. General information

NPI: 1376448456
Provider Name (Legal Business Name): PEDIATRIC GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 CEDAR CT
CARBONDALE IL
62901-5333
US

IV. Provider business mailing address

3412 OFFICE PARK DR
MARION IL
62959-6477
US

V. Phone/Fax

Practice location:
  • Phone: 618-993-0404
  • Fax: 618-993-1717
Mailing address:
  • Phone: 618-993-0404
  • Fax: 618-993-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: RHONDA LYNN FISHER
Title or Position: CEO
Credential:
Phone: 618-993-0404