Provider Demographics
NPI:1689695025
Name:COHEN, REBECCA J (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:COHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3239
Mailing Address - Country:US
Mailing Address - Phone:812-330-3689
Mailing Address - Fax:812-331-3656
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-330-3689
Practice Address - Fax:812-331-3656
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062441A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200828010Medicaid
INM400021626Medicare PIN
IN200828010Medicaid