Basic Information
| Provider Information | |||||||||
| NPI: | 1568621928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERRIN PEDIATRICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4860 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8433574940 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 N 13TH ST | ||||||||
| Address2: | |||||||||
| City: | HERRIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629483248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189886600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 06/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHANMUGAM | ||||||||
| AuthorizedOfficialFirstName: | CHAMUNDAMBIKA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6189886600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036114856 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036114856 | 05 | IL | MEDICAID |