Basic Information
Provider Information | |||||||||
NPI: | 1346218799 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INDIANA UNIVERSITY HEALTH BEDFORD, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | IU HEALTH BEDFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 16TH ST | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | IN | ||||||||
PostalCode: | 474213510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122751200 | ||||||||
FaxNumber: | 8122751370 | ||||||||
Practice Location | |||||||||
Address1: | 2900 16TH ST | ||||||||
Address2: |   | ||||||||
City: | BEDFORD | ||||||||
State: | IN | ||||||||
PostalCode: | 474213510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122751200 | ||||||||
FaxNumber: | 8122751370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2006 | ||||||||
LastUpdateDate: | 10/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DYKES | ||||||||
AuthorizedOfficialFirstName: | BRADFORD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8122751200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X |   | IN | Y |   | Transportation Services | Ambulance |   |
ID Information
ID | Type | State | Issuer | Description | 237402323 | 01 | IN | COMMERCIAL | OTHER | 200033230A | 05 | IN |   | MEDICAID | 000000097631 | 01 | IN | ANTHEM PROV. | OTHER |