Basic Information
| Provider Information | |||||||||
| NPI: | 1083766281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 EASTERN PKWY | ||||||||
| Address2: | SUITE 2313 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402171417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023099800 | ||||||||
| FaxNumber: | 5023099797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 001579 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000964014 | 01 | KY | ANTHEM BCBS | OTHER | 87015798 | 05 | KY | MEDICAID | 001579 | 01 | KY | LICENSE | OTHER | 002124 | 01 | CERTIFICATION - LYMPHOLOGY ASSOCIATION OF NORTH AMERICA | OTHER |