Basic Information
| Provider Information | |||||||||
| NPI: | 1992752612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JASPER PEDIATRIC ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 W 13TH ST | ||||||||
| Address2: | STE 321 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124827918 | ||||||||
| FaxNumber: | 8126341644 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 W 13TH ST | ||||||||
| Address2: | STE 321 | ||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124827918 | ||||||||
| FaxNumber: | 8126341644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KREILEIN | ||||||||
| AuthorizedOfficialFirstName: | NORMA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8124827918 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.