Basic Information
Provider Information | |||||||||
NPI: | 1053759092 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOOD | ||||||||
FirstName: | BRANDON | ||||||||
MiddleName: | ROYCE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2605 E CREEKS EDGE DR | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474018368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2605 E CREEKS EDGE DR | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474018368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123332663 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2013 | ||||||||
LastUpdateDate: | 01/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 01082111A | IN | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | 2018-00463 | NC | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | NC3387 | 05 | SC |   | MEDICAID | 1053759092 | 05 | NC |   | MEDICAID | 0397730024 | 01 | NC | NSC # | OTHER |