Healthcare Provider Details

I. General information

NPI: 1851391262
Provider Name (Legal Business Name): MIDWEST NEUROLOGICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 PROFESSIONAL BLVD STE 201
EVANSVILLE IN
47714-8007
US

IV. Provider business mailing address

1312 PROFESSIONAL BLVD STE 201
EVANSVILLE IN
47714-8007
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-7523
  • Fax: 812-476-6686
Mailing address:
  • Phone: 812-476-7523
  • Fax: 812-476-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number50003893A
License Number StateIN

VIII. Authorized Official

Name: MRS. KEM FRAZEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 812-476-7523