Provider Demographics
NPI:1043279813
Name:OHIO VALLEY COLON & RECTAL SURGEONS, INC.
Entity Type:Organization
Organization Name:OHIO VALLEY COLON & RECTAL SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:812-301-8110
Mailing Address - Street 1:801 SAINT MARYS DR
Mailing Address - Street 2:STE 300 W
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0511
Mailing Address - Country:US
Mailing Address - Phone:812-477-9241
Mailing Address - Fax:812-474-6708
Practice Address - Street 1:801 ST. MARY'S DRIVE WEST
Practice Address - Street 2:SUITE 300
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0560
Practice Address - Country:US
Practice Address - Phone:812-477-9241
Practice Address - Fax:812-474-6708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50002315A208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65908493Medicaid
IN000000056135OtherANTHEM BC/BS
IN100246770AMedicaid