Basic Information
| Provider Information | |||||||||
| NPI: | 1851394175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANOFF | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 N SECTION ST PO BOX 10 | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478820010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122682556 | ||||||||
| FaxNumber: | 8122682652 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 N SECTION ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SULLIVAN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478820010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122682556 | ||||||||
| FaxNumber: | 8122682652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 01053652A | IN | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000338733 | 01 | IN | BLUE CROSS & BLUE SHIELD | OTHER | 200262220 | 05 | IN | MEDICAID | P01625340 | 01 | IN | RAILROAD MEDICARE | OTHER |