MEDICARE: PHYSICAL MEDICINE AND REHABILITATION

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	261QP3300X	Pain Clinic/Center	01035716A	IN

General Provider Information

NPI Number	:	1467907907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL MEDICINE AND REHABILITATION

Provider Business Mailing Address
First Line	:	1146 WASHINGTON SQ
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-6809
Country	:	US
Telephone Number	:	812-426-2662
Fax Number	:	812-426-3141

Provider Business Practice Location Address
First Line	:	1146 WASHINGTON SQ
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-6809
Country	:	US
Telephone Number	:	812-426-2662
Fax Number	:	812-426-3141

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID WILLIAM JOHNSON
Credential	:	MD
Telephone Number	:	812-425-2662

Provider Enumeration Date	:	08/24/2016
Last Update Date	:	08/24/2016

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