Provider Demographics
NPI:1114292208
Name:PRIMUS, SALLY G (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:G
Last Name:PRIMUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1449 KIMBER LN STE 102A
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4067
Mailing Address - Country:US
Mailing Address - Phone:812-616-2020
Mailing Address - Fax:812-616-1400
Practice Address - Street 1:1449 KIMBER LN STE 102A
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4067
Practice Address - Country:US
Practice Address - Phone:126-162-0208
Practice Address - Fax:812-616-1400
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01076710A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201185390Medicaid
IN201185390Medicaid