Healthcare Provider Details

I. General information

NPI: 1639584766
Provider Name (Legal Business Name): ANNA MAIN AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S JORDAN AVE
BLOOMINGTON IN
47405-7002
US

IV. Provider business mailing address

200 S JORDAN AVE
BLOOMINGTON IN
47405-7002
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-7439
  • Fax:
Mailing address:
  • Phone: 812-855-7439
  • Fax: 812-855-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002514A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: