=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003954884
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOARD OF TRUSTEES OF WELBORN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2007
-----------------------------------------------------
Last Update Date | 11/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N RICHLAND CREEK DR
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47670-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-386-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 N RICHLAND CREEK DR
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47670-3536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-386-6650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. DAVID D CHRISTESON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 812-426-6626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085B0100X
-----------------------------------------------------
Taxonomy Name | Body Imaging Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------