Basic Information
| Provider Information | |||||||||
| NPI: | 1558314260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNITY PHYSICIAN GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4777 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474024777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Practice Location | |||||||||
| Address1: | 1155 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474045016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | BISHOP | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8123361690 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207P00000X | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100143140 | 05 | IN | MEDICAID |