Provider Demographics
NPI:1376679753
Name:WILLIAM D PROVINCE MD INC
Entity Type:Organization
Organization Name:WILLIAM D PROVINCE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:PROVINCE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:317-736-7177
Mailing Address - Street 1:100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-1721
Mailing Address - Country:US
Mailing Address - Phone:317-736-7177
Mailing Address - Fax:317-736-7995
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-1721
Practice Address - Country:US
Practice Address - Phone:317-736-7177
Practice Address - Fax:317-736-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50001108A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INB28869Medicare UPIN
IN442430Medicare ID - Type Unspecified