Healthcare Provider Details

I. General information

NPI: 1003801218
Provider Name (Legal Business Name): MARTHA LOUISE UEBELHOER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 MCINTYRE DR SUITE 150
BLOOMINGTON IN
47403-4221
US

IV. Provider business mailing address

PO BOX 5635 ATTN: MARIA MITCHELL
BLOOMINGTON IN
47407-5635
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-7246
  • Fax: 812-333-4471
Mailing address:
  • Phone: 812-337-5003
  • Fax: 812-337-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28105421A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: