1386762318 NPI number — BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY GROUP

Table of content: (NPI 1386762318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386762318 NPI number — BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY GROUP
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:
Provider Other Organization Name Type Code:
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:
1386762318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
637 S WALKER STREET
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47403-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-323-9700
Provider Business Mailing Address Fax Number:
812-323-9701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
637 S WALKER STREET
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-2154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-323-9700
Provider Business Practice Location Address Fax Number:
812-323-9701
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TATE
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
E
Authorized Official Title or Position:
DOCTOR PRESIDENT
Authorized Official Telephone Number:
812-323-9700

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  IN12010196A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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