MEDICARE: ERIC A NISSWANDT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01055787A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000265532	OTHER	IN	BCBS

General Provider Information

NPI Number	:	1366411928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC A NISSWANDT M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1510
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47706-1510
Country	:	US
Telephone Number	:	812-450-6815
Fax Number	:	812-450-6822

Provider Business Practice Location Address
First Line	:	3844 1ST AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47710-3326
Country	:	US
Telephone Number	:	812-428-6161
Fax Number	:	812-421-2883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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