Provider Demographics
NPI:1629027800
Name:EVANSVILLE PRIMARY CARE LLC
Entity Type:Organization
Organization Name:EVANSVILLE PRIMARY CARE LLC
Other - Org Name:EVANSVILLE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTACESSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-479-6907
Mailing Address - Street 1:4933 E PLAZA EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-2813
Mailing Address - Country:US
Mailing Address - Phone:812-401-8720
Mailing Address - Fax:812-479-6967
Practice Address - Street 1:4933 E PLAZA EAST BLVD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2813
Practice Address - Country:US
Practice Address - Phone:812-479-6907
Practice Address - Fax:812-479-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200321590Medicaid
IN1912987363Medicaid
IN192750Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER