Basic Information
Provider Information | |||||||||
NPI: | 1699767871 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARTU | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5545 | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479035545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7654488000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1701 S CREASY LN | ||||||||
Address2: |   | ||||||||
City: | LAFAYETTE | ||||||||
State: | IN | ||||||||
PostalCode: | 479054972 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7655024917 | ||||||||
FaxNumber: | 7655024023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/16/2005 | ||||||||
LastUpdateDate: | 11/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 55097 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 28198251A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000000731643 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER | 100430490A | 05 | KS |   | MEDICAID | 201034820 | 05 | IN |   | MEDICAID |