Provider Demographics
NPI:1962421990
Name:GEORGE M. WOLVERTON M.D. INC.
Entity type:Organization
Organization Name:GEORGE M. WOLVERTON M.D. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-282-4309
Mailing Address - Street 1:8009 WEYANOKE CT
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9426
Mailing Address - Country:US
Mailing Address - Phone:502-292-0428
Mailing Address - Fax:
Practice Address - Street 1:300 SPRING ST STE 3B
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3498
Practice Address - Country:US
Practice Address - Phone:812-282-4309
Practice Address - Fax:812-283-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000563207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN011760466OtherRAILROAD MEDICARE
IN310880Medicare PIN