Healthcare Provider Details

I. General information

NPI: 1154370609
Provider Name (Legal Business Name): RAYMOND E CONN HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 SPRING ST
JEFFERSONVILLE IN
47130-2940
US

IV. Provider business mailing address

1516 SPRING ST
JEFFERSONVILLE IN
47130-2940
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-3676
  • Fax: 812-282-3697
Mailing address:
  • Phone: 812-282-3676
  • Fax: 812-282-3697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number53
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17000464
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: