Basic Information
| Provider Information | |||||||||
| NPI: | 1265534986 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REPETTO | ||||||||
| FirstName: | CORINNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1155 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474045016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123536821 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01037634A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200163730 | 05 | IN | MEDICAID | 01037634A | 01 | IN | IN LICENSE | OTHER | 01037634B | 01 | CSR | OTHER | BR1901316 | 01 | DEA | OTHER |