Healthcare Provider Details

I. General information

NPI: 1487290615
Provider Name (Legal Business Name): PEDIATRIC GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 10/23/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S LINCOLN BLVD
CENTRALIA IL
62801-3654
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 Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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