Healthcare Provider Details

I. General information

NPI: 1629027800
Provider Name (Legal Business Name): EVANSVILLE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4933 E PLAZA EAST BLVD
EVANSVILLE IN
47715-2813
US

IV. Provider business mailing address

4933 E PLAZA EAST BLVD
EVANSVILLE IN
47715-2813
US

V. Phone/Fax

Practice location:
  • Phone: 812-479-6907
  • Fax: 812-479-6967
Mailing address:
  • Phone: 812-401-8720
  • Fax: 812-479-6967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAYLYNN CANTACESSI
Title or Position: MANAGER
Credential:
Phone: 812-479-6907