MEDICARE: EVANSVILLE PRIMARY CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208000000X	Pediatrics Physician
2	363L00000X	Nurse Practitioner
3	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629027800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANSVILLE PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	4933 E PLAZA EAST BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-2813
Country	:	US
Telephone Number	:	812-401-8720
Fax Number	:	812-479-6967

Provider Business Practice Location Address
First Line	:	4933 E PLAZA EAST BLVD
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-2813
Country	:	US
Telephone Number	:	812-479-6907
Fax Number	:	812-479-6967

Authorized Official
Title or Position	:	MANAGER
Name	:	KAYLYNN CANTACESSI
Credential	:
Telephone Number	:	812-479-6907

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/01/2023

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Directions to “EVANSVILLE PRIMARY CARE LLC ” Practice Location

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