Healthcare Provider Details

I. General information

NPI: 1336574490
Provider Name (Legal Business Name): PLAZA PARK FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3799 VENETIAN WAY
NEWBURGH IN
47630-8278
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 812-471-4302
  • Fax: 812-471-4303
Mailing address:
  • Phone: 812-473-0181
  • Fax: 812-473-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036788A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateIN

VIII. Authorized Official

Name: CARLEEN M RUBEL
Title or Position: PRESIDENT
Credential: NP
Phone: 812-471-4302