Healthcare Provider Details

I. General information

NPI: 1003914920
Provider Name (Legal Business Name): BLOOMINGTON DERMATOLOGY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/21/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 E 3RD ST
BLOOMINGTON IN
47401-7890
US

IV. Provider business mailing address

2001 E 3RD ST
BLOOMINGTON IN
47401-7890
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-0398
  • Fax: 812-333-0698
Mailing address:
  • Phone: 812-333-0398
  • Fax: 812-333-0698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01042083A
License Number StateIN

VIII. Authorized Official

Name: SCOTT M WILHELMUS
Title or Position: C.E.O.
Credential: M.D.
Phone: 812-333-0398