Basic Information
Provider Information | |||||||||
NPI: | 1336574490 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PLAZA PARK FAMILY PRACTICE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3276 | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477313276 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124730181 | ||||||||
FaxNumber: | 8124735822 | ||||||||
Practice Location | |||||||||
Address1: | 3799 VENETIAN WAY | ||||||||
Address2: |   | ||||||||
City: | NEWBURGH | ||||||||
State: | IN | ||||||||
PostalCode: | 476308278 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124714302 | ||||||||
FaxNumber: | 8124714303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2013 | ||||||||
LastUpdateDate: | 01/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUBEL | ||||||||
AuthorizedOfficialFirstName: | CARLEEN | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8124714302 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NP | ||||||||
NPICertificationDate: | 01/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X |   | IN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207Q00000X | 01036788A | IN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | DU3406 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000840875 | 01 | IN | ANTHEM | OTHER | 201195100 | 05 | IN |   | MEDICAID |