Healthcare Provider Details

I. General information

NPI: 1306816665
Provider Name (Legal Business Name): BLOOMINGTON ENT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 W 3RD ST
BLOOMINGTON IN
47404-5029
US

IV. Provider business mailing address

1791 W 3RD ST
BLOOMINGTON IN
47404-5029
US

V. Phone/Fax

Practice location:
  • Phone: 812-335-1300
  • Fax: 812-335-0300
Mailing address:
  • Phone: 812-335-1300
  • Fax: 812-335-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01040385A
License Number StateIN

VIII. Authorized Official

Name: JESSE PHILLIPS
Title or Position: OWNER
Credential: MD
Phone: 812-335-1300