Provider Demographics
NPI:1952334252
Name:WALL STREET INTERNAL MEDICINE
Entity Type:Organization
Organization Name:WALL STREET INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:NEVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-288-8360
Mailing Address - Street 1:73 QUARTER MASTER CRT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3759
Mailing Address - Country:US
Mailing Address - Phone:812-288-8360
Mailing Address - Fax:812-288-8375
Practice Address - Street 1:73 QUARTER MASTER CRT
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3759
Practice Address - Country:US
Practice Address - Phone:812-288-8360
Practice Address - Fax:812-288-8375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF56042Medicare UPIN
INS89600Medicare UPIN