Healthcare Provider Details

I. General information

NPI: 1780637058
Provider Name (Legal Business Name): INDIANA UNIVERSITY MEDICAL GENETICS SERVICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 W WALNUT ST
INDIANAPOLIS IN
46202-5181
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 130
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-2966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License Number
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207SM0001X
TaxonomyMolecular Genetic Pathology (Medical Genetics) Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. BRYAN E HAINLINE
Title or Position: PHYSICIAN
Credential: MD, PHD
Phone: 317-274-2966