Healthcare Provider Details

I. General information

NPI: 1386674513
Provider Name (Legal Business Name): PEDIATRIC & INTERNAL MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 CHESTER BLVD
RICHMOND IN
47374-1947
US

IV. Provider business mailing address

1434 CHESTER BLVD
RICHMOND IN
47374-1947
US

V. Phone/Fax

Practice location:
  • Phone: 765-966-5527
  • Fax: 765-966-5527
Mailing address:
  • Phone: 765-966-5527
  • Fax: 765-966-5527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number50000450A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50000450A
License Number StateIN

VIII. Authorized Official

Name: PAMELA CAWOOD
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 765-966-5527