Healthcare Provider Details

I. General information

NPI: 1922462811
Provider Name (Legal Business Name): GREEN PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8247 WICKER AVE
SAINT JOHN IN
46373-8878
US

IV. Provider business mailing address

PO BOX 1153
CROWN POINT IN
46308-1153
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-3931
  • Fax:
Mailing address:
  • Phone: 219-662-3931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01064437A
License Number StateIN

VIII. Authorized Official

Name: DR. BILJANA UZELAC
Title or Position: OWNER / PRESIDENT
Credential: M.D.
Phone: 219-662-3931