Healthcare Provider Details

I. General information

NPI: 1639109945
Provider Name (Legal Business Name): EMERGENCY MEDICINE PROFESSIONALS OF INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 SO MONROE MEDICAL PARK BLVD
BLOOMINGTON IN
47403-9765
US

IV. Provider business mailing address

PO BOX 1204
INDIANAPOLIS IN
46206-1204
US

V. Phone/Fax

Practice location:
  • Phone: 812-824-5700
  • Fax: 812-825-0766
Mailing address:
  • Phone: 317-802-3160
  • Fax: 317-870-0499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK E MANSHIP
Title or Position: PRESIDENT
Credential: MD
Phone: 317-870-0480