Basic Information
Provider Information | |||||||||
NPI: | 1255398202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ORTH | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 550 S LANDMARK AVE | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474033239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123335976 | ||||||||
FaxNumber: | 8123335978 | ||||||||
Practice Location | |||||||||
Address1: | 550 LANDMARK AVE | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 47403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123335976 | ||||||||
FaxNumber: | 8123335978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 12/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 02003057A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 200814200 | 05 | IN |   | MEDICAID |