Provider Demographics
NPI:1033203021
Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Entity Type:Organization
Organization Name:BOARD OF TRUSTEES OF WELBORN CLINIC
Other - Org Name:WELBORN CLINIC UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-426-6626
Mailing Address - Street 1:421 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47713-1227
Mailing Address - Country:US
Mailing Address - Phone:812-426-9855
Mailing Address - Fax:
Practice Address - Street 1:421 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1227
Practice Address - Country:US
Practice Address - Phone:812-426-9855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN849900Medicare ID - Type UnspecifiedMEDICARE GROUP ID