Healthcare Provider Details

I. General information

NPI: 1225169196
Provider Name (Legal Business Name): PEDIATRIC PULMONARY & CRITICAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 WEST JEFFERSON BLVD. STE 205
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

PMB 218 10214 CHESTNUT PLAZA DRIVE
FORT WAYNE IN
46814-8970
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7800
  • Fax: 260-435-7007
Mailing address:
  • Phone: 260-435-7800
  • Fax: 260-435-7007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number01049779A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number01049779A
License Number StateIN

VIII. Authorized Official

Name: CHANDRASHEKHAR CHOWDARY YALAMANCHALI
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 260-435-7800