Basic Information
| Provider Information | |||||||||
| NPI: | 1275600306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLSTER | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.S., O.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WRIGHT | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.S., O.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 744 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128558436 | ||||||||
| FaxNumber: | 8128551683 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474053603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128558436 | ||||||||
| FaxNumber: | 8128551683 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | 31002137A | IN | N | Eye and Vision Services Providers | Technician/Technologist | 225XL0004X | 31002137A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Low Vision |
ID Information
| ID | Type | State | Issuer | Description | 200854470 | 05 | IN | MEDICAID | 000000584866 | 01 | IN | ANTHEM | OTHER |