Provider Demographics
NPI:1467907907
Name:PHYSICAL MEDICINE AND REHABILITATION
Entity Type:Organization
Organization Name:PHYSICAL MEDICINE AND REHABILITATION
Other - Org Name:MEDICAL PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-425-2662
Mailing Address - Street 1:1146 WASHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-6809
Mailing Address - Country:US
Mailing Address - Phone:812-426-2662
Mailing Address - Fax:812-426-3141
Practice Address - Street 1:1146 WASHINGTON SQ
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-6809
Practice Address - Country:US
Practice Address - Phone:812-426-2662
Practice Address - Fax:812-426-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035716A261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain