1821196221 NPI number — DR. KEITH M WELLS MD

Table of content: DR. KEITH M WELLS MD (NPI 1821196221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821196221 NPI number — DR. KEITH M WELLS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WELLS
Provider First Name:
KEITH
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821196221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47732-3366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-450-2240
Provider Business Mailing Address Fax Number:
812-450-2710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MARY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47747-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-450-2240
Provider Business Practice Location Address Fax Number:
812-450-2710
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  01053326A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000199793 . This is a "BCBS PIN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000501016 . This is a "BCBS - DECONESS GATEWAY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: P00302922 . This is a "RR MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200326590 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64041734 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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