NPIMap

Organization Active NPI

Medical Center for Children & Adolescents, PA

Doing business as The Pediatric Center

  • Pediatrics Physician
  • Idaho Falls, ID
National Provider Identifier
1073528998
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA
Doing business as
The Pediatric Center
Practice address
3430 Washington Pkwy
Idaho Falls, ID 83404-7579
Phone
(208) 523-3060
NPI assigned
Jul 29, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Michael Jude Pankau, M.D.NPI 1558475111
Title
President
Phone
(208) 523-3060

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NU Primary

Addresses

Primary practice location

3430 Washington Pkwy
Idaho Falls, ID 83404-7579

Mailing address

3430 Washington Pkwy
Idaho Falls, ID 83404-7579
Phone (208) 523-3060

Other identifiers 2

IdentifierTypeStateIssuer
85456OtherIDBLUE CROSS
000010006561OtherIDBLUE SHIELD

Other names 1

  • The Pediatric Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120404000658 ID Part B Supplier - Clinic/Group Practice 5496915159 Receives reassigned benefits from 1 practitioner
Practice locations: Idaho Falls, ID

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D0520814Pediatric Center, the3430 Washington Pkwy, Idaho Falls, ID 83404ComplianceNov 10, 2027

National Provider Directory

National Provider Directory

Locations

530 Rigby Lake Dr
Rigby, ID 83442
Phone (208) 745-5021

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154131200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1073528998",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3430 WASHINGTON PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047579",
            "telephone_number": "208-523-3060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3430 WASHINGTON PKWY",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "834047579",
            "telephone_number": "208-523-3060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL CENTER FOR CHILDREN & ADOLESCENTS, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-29",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "PANKAU",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "JUDE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "208-523-3060",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS",
            "identifier": "85456",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "000010006561",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Pediatric Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.