Basic Information
| Provider Information | |||||||||
| NPI: | 1629533872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLODGETT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BLODGETTT | ||||||||
| OtherFirstName: | TOM | ||||||||
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| OtherCredential: | PHD, RN, AGACNP-BC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199322300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 71008704A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | 71008704A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 300023860 | 05 | IN | MEDICAID |