Healthcare Provider Details

I. General information

NPI: 1346628492
Provider Name (Legal Business Name): PEDIATRIC SPECIALTY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2015
Last Update Date: 05/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6437 RUCKER RD SUITE D
INDIANAPOLIS IN
46220-4885
US

IV. Provider business mailing address

6437 RUCKER RD SUITE D
INDIANAPOLIS IN
46220-4885
US

V. Phone/Fax

Practice location:
  • Phone: 317-405-9016
  • Fax:
Mailing address:
  • Phone: 317-405-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number22005410A
License Number StateIN

VIII. Authorized Official

Name: DONNA HOLTZ
Title or Position: OWNER
Credential:
Phone: 317-405-9016