Healthcare Provider Details

I. General information

NPI: 1790837789
Provider Name (Legal Business Name): PHYSICIAN'S PRACTICE ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 18TH ST SUITE 210
COLUMBUS IN
47201-5359
US

IV. Provider business mailing address

2326 18TH ST SUITE 210
COLUMBUS IN
47201-5359
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8426
  • Fax: 812-372-8301
Mailing address:
  • Phone: 812-372-8426
  • Fax: 812-372-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01037446
License Number StateIN

VIII. Authorized Official

Name: MR. MIKE ROBERTSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 812-372-8426