=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710191747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEBRON PEDIATRICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7220 E VIRGINIA ST
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-4068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-473-8986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7220 E VIRGINIA ST
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-4068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE ADMINISTRATOR
-----------------------------------------------------
Name | DIANA LAMONT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-402-9171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080A0000X
-----------------------------------------------------
Taxonomy Name | Pediatric Adolescent Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------