Basic Information
| Provider Information | |||||||||
| NPI: | 1437256146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP OF INDIANA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 CONCORD TER STE 300 | ||||||||
| Address2: | |||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333232843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8042530408 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 N MICHIGAN ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742342287 | ||||||||
| FaxNumber: | 5742345803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | OLIVER | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 9543840175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200135170B | 05 | IN | MEDICAID | 00135170C | 05 | IN | MEDICAID | 00135170F | 05 | IN | MEDICAID | 200135170C | 05 | IN | MEDICAID | 200135170G | 05 | IN | MEDICAID | 200135170F | 05 | IN | MEDICAID | 200135170A | 05 | IN | MEDICAID | 200135170D | 05 | IN | MEDICAID | 00135170A | 05 | IN | MEDICAID | 00135170D | 05 | IN | MEDICAID | 00135170B | 05 | IN | MEDICAID | 200135170I | 05 | IN | MEDICAID | 00135170G | 05 | IN | MEDICAID |