Healthcare Provider Details

I. General information

NPI: 1649204082
Provider Name (Legal Business Name): BEATRICE CLAIRE TRAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

438 POPCORN RD
SPRINGVILLE IN
47462-5321
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-9453
  • Fax:
Mailing address:
  • Phone: 812-279-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01040114A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: