Healthcare Provider Details

I. General information

NPI: 1396284410
Provider Name (Legal Business Name): BLOOMINGTON EMERGENCY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 S MONROE MEDICAL PARK BLVD
BLOOMINGTON IN
47403-8000
US

IV. Provider business mailing address

4011 S MONROE MEDICAL PARK BLVD
BLOOMINGTON IN
47403-8000
US

V. Phone/Fax

Practice location:
  • Phone: 812-825-1111
  • Fax:
Mailing address:
  • Phone: 812-825-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: ERIKA O'BRIEN
Title or Position: COO-CFO
Credential:
Phone: 765-446-0170