Basic Information
| Provider Information | |||||||||
| NPI: | 1952466435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ECKART | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W RAMPART ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174212012 | ||||||||
| FaxNumber: | 3173981851 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 W RAMPART ST | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173987537 | ||||||||
| FaxNumber: | 3174210372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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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 | 208000000X | 01063201A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200867260 | 05 | IN | MEDICAID |