Basic Information
Provider Information | |||||||||
NPI: | 1922003524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRICE | ||||||||
FirstName: | BERNADETTE | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1040 SIERRA DR | ||||||||
Address2: | SUITE 400 | ||||||||
City: | GREENWOOD | ||||||||
State: | IN | ||||||||
PostalCode: | 461437241 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175284284 | ||||||||
FaxNumber: | 3178658355 | ||||||||
Practice Location | |||||||||
Address1: | 297 W FRANCISCAN DR | ||||||||
Address2: | SUITE 203 | ||||||||
City: | CROWN POINT | ||||||||
State: | IN | ||||||||
PostalCode: | 463074858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2196626151 | ||||||||
FaxNumber: | 2196626156 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 05/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 09000074A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 200314080 | 05 | IN |   | MEDICAID | 000000722777 | 01 | IN | ANTHEM TRADITIONAL | OTHER |