Healthcare Provider Details

I. General information

NPI: 1982693743
Provider Name (Legal Business Name): INDIANA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/01/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S JORDAN AVE
BLOOMINGTON IN
47405-7002
US

IV. Provider business mailing address

2631 EAST DISCOVERY PARKWAY HEALTH SCIENCES BUILDING
BLOOMINGTON IN
47408-9059
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-4156
  • Fax: 812-855-5531
Mailing address:
  • Phone: 812-855-4156
  • Fax: 812-855-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateIN

VIII. Authorized Official

Name: MARCIA A HUMPHRESS
Title or Position: FISCAL OFFICER
Credential:
Phone: 812-855-4156