BOARD OF TRUSTEES OF WELBORN CLINIC

Provider Demographics

• NPI: 1588672992
• Name: BOARD OF TRUSTEES OF WELBORN CLINIC
• Entity Type: Organization
• Organization Name: BOARD OF TRUSTEES OF WELBORN CLINIC
• Other - Org Name: WELBORN CLINIC
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: DAVID
• Authorized Official - Middle Name: D
• Authorized Official - Last Name: CHRISTESON
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 812-426-6626
• Mailing Address - Street 1: 421 CHESTNUT ST
• Mailing Address - City: EVANSVILLE
• Mailing Address - State: IN
• Mailing Address - Zip Code: 47713-1227
• Mailing Address - Country: US
• Mailing Address - Phone: 812-426-6626
• Practice Address - Street 1: 421 CHESTNUT ST
• Practice Address - City: EVANSVILLE
• Practice Address - State: IN
• Practice Address - Zip Code: 47713-1227
• Practice Address - Country: US
• Practice Address - Phone: 812-426-6626
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-08-03
• Last Update Date: 2009-02-05

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261Q00000X	Ambulatory Health Care Facilities	Clinic/Center		Group - Multi-Specialty
No	103T00000X	Behavioral Health & Social Service Providers	Psychologist		Group - Multi-Specialty
No	152W00000X	Eye and Vision Services Providers	Optometrist		Group - Multi-Specialty
No	207K00000X	Allopathic & Osteopathic Physicians	Allergy & Immunology		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	207W00000X	Allopathic & Osteopathic Physicians	Ophthalmology		Group - Multi-Specialty
No	207X00000X	Allopathic & Osteopathic Physicians	Orthopaedic Surgery		Group - Multi-Specialty
No	208000000X	Allopathic & Osteopathic Physicians	Pediatrics		Group - Multi-Specialty
No	208800000X	Allopathic & Osteopathic Physicians	Urology		Group - Multi-Specialty
No	213E00000X	Podiatric Medicine & Surgery Service Providers	Podiatrist		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	363LA2100X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Acute Care	Group - Multi-Specialty
No	363LA2200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Adult Health	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	100240870	Medicaid
IN	533600	Medicare PIN
IN	533890	Medicare PIN
IN	849860	Medicare PIN
IN	849810	Medicare PIN
IN	849870	Medicare PIN
IN	533180	Medicare PIN
IN	849800	Medicare PIN
IN	849820	Medicare PIN
IN	881830	Medicare PIN
IN	849880	Medicare PIN
IN	839900	Medicare PIN
IN	839980	Medicare PIN
IN	849790	Medicare PIN
IN	849840	Medicare PIN
IN	281690	Medicare PIN
IN	839920	Medicare PIN
IN	849900	Medicare PIN
IN	881810	Medicare PIN
IN	533200	Medicare PIN
IN	750580	Medicare PIN
IN	839910	Medicare PIN
IN	849830	Medicare PIN
IN	849850	Medicare PIN
IN	849890	Medicare PIN