Healthcare Provider Details

I. General information

NPI: 1457572596
Provider Name (Legal Business Name): CASANA RAE SIEBERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASANA RAE BRUNTON MD

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 2ND ST
BLOOMINGTON IN
47403-2317
US

IV. Provider business mailing address

315 W KIRKWOOD AVE APT 407
BLOOMINGTON IN
47404-5175
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-6821
  • Fax:
Mailing address:
  • Phone: 316-213-4738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6580
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01074372A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: