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General NPI Number Information
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NPI Number | 1023582038
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Entity Type | Organization
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Legal Business Name | PEDIATRIC GROUP LLC
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Dates
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Enumeration Date | 01/14/2019
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 1175 CEDAR CT
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City | CARBONDALE
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State | IL
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Zip | 62901-5333
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Country | US
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Telephone | 618-993-0404
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Fax | 618-993-1717
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Provider Business Mailing Address
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Address Line | 3412 OFFICE PARK DR
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City | MARION
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State | IL
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Zip | 62959-6477
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Country | US
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Telephone | 618-993-0404
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Fax | 618-993-0404
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | RHONDA LYNN FISHER
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Credential |
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Telephone | 618-993-0404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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