Healthcare Provider Details

I. General information

NPI: 1073164646
Provider Name (Legal Business Name): INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 E JACKSON ST
MUNCIE IN
47303-4432
US

IV. Provider business mailing address

1200 W WHITE RIVER BLVD ATTN: PROVIDER ENROLLMENT
MUNCIE IN
47303-4988
US

V. Phone/Fax

Practice location:
  • Phone: 765-254-9717
  • Fax: 765-254-9739
Mailing address:
  • Phone: 765-282-8991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN VANATOR
Title or Position: CFO
Credential:
Phone: 765-741-2891