Provider Demographics
NPI:1356727218
Name:INTERNAL MEDICINE OF THE WABASH VALLEY P.C.
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF THE WABASH VALLEY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STOCKRAHM
Authorized Official - Suffix:
Authorized Official - Credentials:DO, CMD
Authorized Official - Phone:812-235-7252
Mailing Address - Street 1:1600 E SPRINGHILL DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4363
Mailing Address - Country:US
Mailing Address - Phone:812-235-7252
Mailing Address - Fax:812-235-7176
Practice Address - Street 1:2223 WABASH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3305
Practice Address - Country:US
Practice Address - Phone:812-235-7252
Practice Address - Fax:812-235-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200227720AMedicaid
IN186170Medicare UPIN