Provider Demographics
NPI:1487290615
Name:PEDIATRIC GROUP, LLC
Entity type:Organization
Organization Name:PEDIATRIC GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-993-0404
Mailing Address - Street 1:3412 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-6477
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:618-993-1717
Practice Address - Street 1:130 S LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3654
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:618-993-1717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-22
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty