Basic Information
| Provider Information | |||||||||
| NPI: | 1063887438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAVILION PEDIATRIC CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652319494 | ||||||||
| FaxNumber: | 7655874456 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652319494 | ||||||||
| FaxNumber: | 7655874456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | BHOOPALAM | ||||||||
| AuthorizedOfficialFirstName: | PRAKASH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7652319494 | ||||||||
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| 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 | 01040631A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201328850 | 05 | IN | MEDICAID | 201337310A | 05 | IN | MEDICAID | 100362560 | 05 | IN | MEDICAID |