Basic Information
| Provider Information | |||||||||
| NPI: | 1356532113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLOOMINGTON SLEEP SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2920 MCINTYRE DR | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474034221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123327337 | ||||||||
| FaxNumber: | 8123392934 | ||||||||
| Practice Location | |||||||||
| Address1: | 2920 MCINTYRE DR | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474034221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123327337 | ||||||||
| FaxNumber: | 8123392934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCBRIDE | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8123327337 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 2084S0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine | 207YS0012X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine |
No ID Information.