Healthcare Provider Details

I. General information

NPI: 1083213607
Provider Name (Legal Business Name): MEDIHEALTH PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2345 W FRANKLIN ST STE 102
EVANSVILLE IN
47712-5100
US

IV. Provider business mailing address

2345 W FRANKLIN ST STE 102
EVANSVILLE IN
47712-5100
US

V. Phone/Fax

Practice location:
  • Phone: 812-270-9903
  • Fax:
Mailing address:
  • Phone: 812-598-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HUBERT REYES
Title or Position: OWNER
Credential: MD
Phone: 812-270-9903