Provider Demographics
NPI:1073504304
Name:PEDIATRIC CARE CLINIC
Entity type:Organization
Organization Name:PEDIATRIC CARE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-703-1619
Mailing Address - Street 1:4320 FIR ST
Mailing Address - Street 2:STE 410
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312
Mailing Address - Country:US
Mailing Address - Phone:219-392-2848
Mailing Address - Fax:219-392-2878
Practice Address - Street 1:4320 FIR ST
Practice Address - Street 2:STE 410
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312
Practice Address - Country:US
Practice Address - Phone:219-392-2848
Practice Address - Fax:219-392-2878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200324900Medicaid