Provider Demographics
NPI:1942368519
Name:ASSOCIATED PEDIATRICIANS, LLC
Entity type:Organization
Organization Name:ASSOCIATED PEDIATRICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID TRICARE SERVICES MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-531-7492
Mailing Address - Street 1:1101 GLENDALE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3767
Mailing Address - Country:US
Mailing Address - Phone:219-531-7492
Mailing Address - Fax:219-548-3681
Practice Address - Street 1:1101 GLENDALE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3767
Practice Address - Country:US
Practice Address - Phone:219-531-7492
Practice Address - Fax:219-548-3681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100439780BMedicaid