Healthcare Provider Details

I. General information

NPI: 1588605349
Provider Name (Legal Business Name): MIDWEST CHILD AND ADOLESCENT SPECIALTY GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E DAVIS DR
TERRE HAUTE IN
47802-4034
US

IV. Provider business mailing address

1310 E DAVIS DR
TERRE HAUTE IN
47802-4034
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-7337
  • Fax: 812-232-7338
Mailing address:
  • Phone: 812-232-7337
  • Fax: 812-232-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01059798A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01059798A
License Number StateIN

VIII. Authorized Official

Name: DR. PABLITO S. DELA CRUZ
Title or Position: OWNER
Credential: M.D.
Phone: 812-232-7337