Provider Demographics
NPI:1336574490
Name:PLAZA PARK FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:PLAZA PARK FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUBEL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:812-471-4302
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:3799 VENETIAN WAY
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8278
Practice Address - Country:US
Practice Address - Phone:812-471-4302
Practice Address - Fax:812-471-4303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036788A207Q00000X
IN363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDU3406OtherRAILROAD MEDICARE
IN000000840875OtherANTHEM
IN201195100Medicaid
IN000000840875OtherANTHEM