Provider Demographics
NPI:1063887438
Name:PAVILION PEDIATRIC CENTER, LLC
Entity type:Organization
Organization Name:PAVILION PEDIATRIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RECTOR
Authorized Official - Suffix:
Authorized Official - Credentials:NP/OWNER
Authorized Official - Phone:765-231-9494
Mailing Address - Street 1:3711 N. EVERBROOK LANE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5270
Mailing Address - Country:US
Mailing Address - Phone:765-231-9494
Mailing Address - Fax:765-587-4456
Practice Address - Street 1:3711 N. EVERBROOK LANE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5270
Practice Address - Country:US
Practice Address - Phone:765-231-9494
Practice Address - Fax:765-587-4456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201328850Medicaid
IN201337310AMedicaid
IN100362560Medicaid