MEDICARE: DR. VAN EVANOFF JR. 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	208VP0014X	Interventional Pain Medicine Physician	01053652A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01625340	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000338733	OTHER	IN	BLUE CROSS & BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851394175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VAN EVANOFF JR. M.D.

Provider Business Mailing Address
First Line	:	2204 N SECTION ST PO BOX 10
Second Line	:	SUITE B
City	:	SULLIVAN
State	:	IN
Zip	:	47882-0010
Country	:	US
Telephone Number	:	812-268-2556
Fax Number	:	812-268-2652

Provider Business Practice Location Address
First Line	:	2204 N SECTION ST
Second Line	:	SUITE B
City	:	SULLIVAN
State	:	IN
Zip	:	47882-0010
Country	:	US
Telephone Number	:	812-268-2556
Fax Number	:	812-268-2652

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	05/25/2016

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Directions to “ DR. VAN EVANOFF JR. M.D.” Practice Location

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