MEDICARE: NEW WELLSPRING LLC

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician

General Provider Information

NPI Number	:	1932683471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW WELLSPRING LLC

Provider Business Mailing Address
First Line	:	2400 NORTHPARK DR STE 20
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-4467
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 NORTHPARK DR STE 20
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-4467
Country	:	US
Telephone Number	:	812-376-8625
Fax Number	:

Authorized Official
Title or Position	:	OWNER/AUTHORIZED OFFICIAL
Name	:	RICHARD ROBERTSON
Credential	:	MD
Telephone Number	:	812-376-0700

Provider Enumeration Date	:	09/20/2018
Last Update Date	:	09/20/2018

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Directions to “NEW WELLSPRING LLC ” Practice Location

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