Basic Information
| Provider Information | |||||||||
| NPI: | 1073547154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDIANA UNIVERSITY HEALTH BLOOMINGTON INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | IU HEALTH BLOOMINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123539557 | ||||||||
| FaxNumber: | 8123535228 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123539940 | ||||||||
| FaxNumber: | 8123539941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8123539557 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000000237063 | 01 | IN | ANTHEM REHAB UNIT NUMBER | OTHER |