Provider Demographics
NPI:1265634711
Name:THERESA A. TRAVIS,M.D.,PC
Entity Type:Organization
Organization Name:THERESA A. TRAVIS,M.D.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-275-3328
Mailing Address - Street 1:2516 Q ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-4928
Mailing Address - Country:US
Mailing Address - Phone:812-275-3328
Mailing Address - Fax:812-279-5977
Practice Address - Street 1:2516 Q ST
Practice Address - Street 2:SUITE B
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4928
Practice Address - Country:US
Practice Address - Phone:812-275-3328
Practice Address - Fax:812-279-5977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036752A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN216700Medicare PIN