Healthcare Provider Details

I. General information

NPI: 1659355451
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF AVON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 RONALD REAGAN PKWY SUITE 136
AVON IN
46123-6910
US

IV. Provider business mailing address

1115 RONALD REAGAN PKWY SUITE 136
AVON IN
46123-6910
US

V. Phone/Fax

Practice location:
  • Phone: 317-217-2900
  • Fax: 317-217-2909
Mailing address:
  • Phone: 317-217-2900
  • Fax: 317-217-2909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01038641
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01049242
License Number StateIN

VIII. Authorized Official

Name: DR. DONALD JOY MCINTIRE
Title or Position: PHYSICIAN
Credential: MD
Phone: 317-217-2900