1336538917 NPI number — THE TRUSTEES OF INDIANA UNIVERSITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336538917 NPI number — THE TRUSTEES OF INDIANA UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE TRUSTEES OF INDIANA UNIVERSITY
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:
INDIANA UNIVERSITY SPORTS MEDICINE
Provider Other Organization Name Type Code:
3
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:
1336538917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 SPRING VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75244-3995
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-555-9073
Provider Business Mailing Address Fax Number:
972-367-3452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 E 17TH ST
Provider Second Line Business Practice Location Address:
ASSEMBLY HALL
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47408-1590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-237-3883
Provider Business Practice Location Address Fax Number:
972-367-3451
Provider Enumeration Date:
01/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BASS
Authorized Official First Name:
MOUZON
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
18005559073

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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