MEDICARE: DR. THERESA ANN TRAVIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	01036752	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000344070	OTHER	IN	ANTHEM BCBS

General Provider Information

NPI Number	:	1295778439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA ANN TRAVIS M.D.

Provider Business Mailing Address
First Line	:	2516 Q ST
Second Line	:	SUITE B
City	:	BEDFORD
State	:	IN
Zip	:	47421-4928
Country	:	US
Telephone Number	:	812-275-3328
Fax Number	:	812-279-5977

Provider Business Practice Location Address
First Line	:	2516 Q ST
Second Line	:	SUITE B
City	:	BEDFORD
State	:	IN
Zip	:	47421-4928
Country	:	US
Telephone Number	:	812-275-3328
Fax Number	:	812-279-5977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/08/2007

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