Basic Information
| Provider Information | |||||||||
| NPI: | 1710196969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA UNIVERSITY HEALTH BLOOMINGTON INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IU HEALTH BLOOMINGTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W 2ND ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474032317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123535819 | ||||||||
| FaxNumber: | 8123535228 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 E MILLER DR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474016557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123535819 | ||||||||
| FaxNumber: | 8123535228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | MYERS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8123539551 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | IN | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 200323260 | 05 | IN | MEDICAID |