1104166503 NPI number — EVANSVILLE INTEGRATIVE MEDICINE PC

Table of content: (NPI 1104166503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104166503 NPI number — EVANSVILLE INTEGRATIVE MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVANSVILLE INTEGRATIVE MEDICINE 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:
1104166503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 BELLEMEADE AVE
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47714-0102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-401-4222
Provider Business Mailing Address Fax Number:
812-401-5722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 BELLEMEADE AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47714-0102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-401-4222
Provider Business Practice Location Address Fax Number:
812-401-5722
Provider Enumeration Date:
02/21/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUTSCH
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-401-4222

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  01059401A , 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: 1780600353 . This is a "NPI (PHYSICIAN)" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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