Basic Information
| Provider Information | |||||||||
| NPI: | 1114129970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Practice Location | |||||||||
| Address1: | 3412 OFFICE PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629591998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189930404 | ||||||||
| FaxNumber: | 6189931717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | FISHER | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6189930404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 2080A0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.