MEDICARE: PHYSICIAN'S PRACTICE ORGANIZATION

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	174400000X	Specialist	01037446	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CF9669	OTHER	IN	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1790837789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN'S PRACTICE ORGANIZATION

Provider Business Mailing Address
First Line	:	2326 18TH ST
Second Line	:	SUITE 210
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5359
Country	:	US
Telephone Number	:	812-372-8426
Fax Number	:	812-372-8301

Provider Business Practice Location Address
First Line	:	2326 18TH ST
Second Line	:	SUITE 210
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5359
Country	:	US
Telephone Number	:	812-372-8426
Fax Number	:	812-372-8301

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MR. MIKE ROBERTSON
Credential	:
Telephone Number	:	812-372-8426

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	12/17/2007

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