=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962421990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGE M. WOLVERTON M.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 SPRING ST STE 3B
-----------------------------------------------------
City | JEFFERSONVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47130-3498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-282-4309
-----------------------------------------------------
Fax | 812-283-8299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8009 WEYANOKE CT
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40059-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-292-0428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | DR. STEVEN MITCHELL JOHNSON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 812-282-4309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 50000563
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------