1881630739 NPI number — MED 1ST OF EVANSVILLE, PC

Table of content: (NPI 1881630739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881630739 NPI number — MED 1ST OF EVANSVILLE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED 1ST OF EVANSVILLE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1881630739
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4506
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:
47724-0506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-473-4011
Provider Business Mailing Address Fax Number:
812-474-4581

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 WASHINGTON AVE
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:
47714-2056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-473-4011
Provider Business Practice Location Address Fax Number:
812-474-4581
Provider Enumeration Date:
06/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
POELING
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
812-473-4011

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 156619 . This is a "MEDICARE OUTPATIENT REHAB FACILITY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 5358340001 . This is a "DMERC PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".