Healthcare Provider Details

I. General information

NPI: 1467329185
Provider Name (Legal Business Name): GRACE ELIZABETH PODUCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2025
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 S PARK RIDGE RD STE 101
BLOOMINGTON IN
47401-8589
US

IV. Provider business mailing address

750 N WOODBRIDGE DR
BLOOMINGTON IN
47408-2778
US

V. Phone/Fax

Practice location:
  • Phone: 812-235-8496
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005102A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: