Healthcare Provider Details

I. General information

NPI: 1093192387
Provider Name (Legal Business Name): EVANSVILLE OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 06/13/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7145 E VIRGINIA ST
EVANSVILLE IN
47715-9147
US

IV. Provider business mailing address

7145 E. VIRIGINIA STREET STE 2000
EVANSVILLE IN
47715-9147
US

V. Phone/Fax

Practice location:
  • Phone: 812-853-2229
  • Fax:
Mailing address:
  • Phone: 812-962-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01040195A
License Number StateIN

VIII. Authorized Official

Name: LISA HASTETTER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 812-853-2229