1033298120 NPI number — BLOOMINGTON MEADOWS GP

Table of content: (NPI 1033298120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033298120 NPI number — BLOOMINGTON MEADOWS GP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMINGTON MEADOWS GP
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:
BLOOMINGTON MEADOWS PHYSICIANS
Provider Other Organization Name Type Code:
5
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:
1033298120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3600 N PROW RD
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:
47404-1616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-331-8000
Provider Business Mailing Address Fax Number:
812-331-8985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3600 N PROW RD
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:
47404-1616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-331-8000
Provider Business Practice Location Address Fax Number:
812-331-8985
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FILTON
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP CFO
Authorized Official Telephone Number:
610-768-3300

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  324-1-PIP , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 324-1-PIP , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 71000894A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: 28152858A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0807X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0813X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 060128000 . This is a "MAGELLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 107936 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200075480 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2398043 . This is a "OHIO MEDICAID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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