Provider Demographics
NPI:1689735110
Name:PEDIATRIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PIYUSH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-356-3611
Mailing Address - Street 1:2814 THEATER AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-7978
Mailing Address - Country:US
Mailing Address - Phone:260-356-3611
Mailing Address - Fax:260-358-4263
Practice Address - Street 1:2814 THEATER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-7978
Practice Address - Country:US
Practice Address - Phone:260-356-3611
Practice Address - Fax:260-358-4263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100138140AMedicaid
IN100138140AMedicaid