Basic Information
| Provider Information | |||||||||
| NPI: | 1992749832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARMACK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARY STREET | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506800 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/26/2008 | ||||||||
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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 | 207P00000X | 01058756A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000537665 | 01 | IN | ANTHEM PIN - GATEWAY BLVD | OTHER | 000000539314 | 01 | IN | ANTHEM PIN - MARY ST | OTHER |