Healthcare Provider Details

I. General information

NPI: 1942433610
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY REHAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 RIDGEWOOD CT
FLOYDS KNOBS IN
47119-9435
US

IV. Provider business mailing address

PO BOX 417
FLOYDS KNOBS IN
47119-0417
US

V. Phone/Fax

Practice location:
  • Phone: 502-608-8475
  • Fax: 812-923-0620
Mailing address:
  • Phone: 502-608-8475
  • Fax: 812-923-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number05002026A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number05002026A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000000283356
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerANTHEM

VIII. Authorized Official

Name: MS. CHRISTINA C. MERK
Title or Position: PRESIDENT
Credential: P.T.
Phone: 502-608-8475