MEDICARE: PEDIATRIC REHABILITATION OF INDIANA, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P0010X	Pediatric Rehabilitation Medicine Physician	01043182A	IN

General Provider Information

NPI Number	:	1629286794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC REHABILITATION OF INDIANA, INC

Provider Business Mailing Address
First Line	:	5006 DEER PARK CIR
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78413-6027
Country	:	US
Telephone Number	:	361-548-5270
Fax Number	:

Provider Business Practice Location Address
First Line	:	3825 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4018
Country	:	US
Telephone Number	:	361-548-5270
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUSAN CALDECOTT DIETERICH
Credential	:	MD
Telephone Number	:	361-548-5270

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	08/22/2020

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