Healthcare Provider Details

I. General information

NPI: 1629267323
Provider Name (Legal Business Name): NORTHEAST INDIANA PEDIATRIC SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11123 PARKVIEW PLAZA DR STE # 102
FORT WAYNE IN
46845-1707
US

IV. Provider business mailing address

PO BOX 5191
FORT WAYNE IN
46895-5191
US

V. Phone/Fax

Practice location:
  • Phone: 260-483-0688
  • Fax: 260-483-0798
Mailing address:
  • Phone: 260-483-0688
  • Fax: 260-483-0798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number50004150A
License Number StateIN

VIII. Authorized Official

Name: SHERYL L. ANDERSON
Title or Position: MANAGER
Credential:
Phone: 260-483-0688