Healthcare Provider Details

I. General information

NPI: 1235450867
Provider Name (Legal Business Name): COLEMAN INSTITUTE- INDIANA PETER RICHARD COLEMAN SOLE MBR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 WALL ST SUITE 204
JEFFERSONVILLE IN
47130-3612
US

IV. Provider business mailing address

1035 WALL ST SUITE 204
JEFFERSONVILLE IN
47130-3612
US

V. Phone/Fax

Practice location:
  • Phone: 812-288-8410
  • Fax: 812-288-8409
Mailing address:
  • Phone: 812-288-8410
  • Fax: 812-288-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02001067A
License Number StateIN

VIII. Authorized Official

Name: STEVEN F SHIELDS
Title or Position: BILLING MANAGER
Credential:
Phone: 804-282-9133