1780775163 NPI number — INDIANA UNIVERSITY HEALTH PROTON THERAPY CENTER, LLC

Table of content: (NPI 1780775163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780775163 NPI number — INDIANA UNIVERSITY HEALTH PROTON THERAPY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA UNIVERSITY HEALTH PROTON THERAPY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIDWEST PROTON RADIOTHERAPY INSTITUTE, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780775163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2425 MILO B. SAMPSON LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47408-1398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-349-5074
Provider Business Mailing Address Fax Number:
812-349-5046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2425 MILO B. SAMPSON LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47408-1398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-349-5074
Provider Business Practice Location Address Fax Number:
812-349-5046
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KERSTIENS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO/CFO
Authorized Official Telephone Number:
812-349-5028

Provider Taxonomy Codes

  • Taxonomy code: 261QX0203X , with the licence number:  NA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200442910A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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