MEDICARE: DR. MARK EVENSON MD

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	01032279	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000603583	OTHER	IN	ANTHEM - TIPTON HOSPITAL

General Provider Information

NPI Number	:	1407845746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EVENSON MD

Provider Business Mailing Address
First Line	:	1000 S MAIN ST
Second Line	:
City	:	TIPTON
State	:	IN
Zip	:	46072-9753
Country	:	US
Telephone Number	:	765-675-8521
Fax Number	:	765-675-8520

Provider Business Practice Location Address
First Line	:	1000 S MAIN ST
Second Line	:
City	:	TIPTON
State	:	IN
Zip	:	46072-9753
Country	:	US
Telephone Number	:	765-675-8521
Fax Number	:	765-675-8520

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

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	11/29/2011

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Directions to “ DR. MARK EVENSON MD” Practice Location

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