Healthcare Provider Details

I. General information

NPI: 1669609400
Provider Name (Legal Business Name): BLOOMINGTON ORTHOPEDIC SPINE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 W SUDBURY DR STE C
BLOOMINGTON IN
47403-3812
US

IV. Provider business mailing address

2201 W SUDBURY DR STE C
BLOOMINGTON IN
47403-3812
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-1933
  • Fax: 812-333-3991
Mailing address:
  • Phone: 812-333-1933
  • Fax: 812-333-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number01065333A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number01065333A
License Number StateIN

VIII. Authorized Official

Name: DR. JOHN P HAMMERSTEIN
Title or Position: PRESIDENT
Credential: MD
Phone: 812-333-1933