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General NPI Number Information
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NPI Number | 1003914920
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON DERMATOLOGY CLINIC
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Dates
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Enumeration Date | 09/21/2006
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 2001 E 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-7890
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Country | US
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Telephone | 812-333-0398
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Fax | 812-333-0698
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Provider Business Mailing Address
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Address Line | 2001 E 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47401-7890
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Country | US
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Telephone | 812-333-0398
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Fax | 812-333-0698
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Authorized Official
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Title or Position | C.E.O.
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Name | SCOTT M WILHELMUS
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Credential | M.D.
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Telephone | 812-333-0398
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 01042083A
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License Number State | IN
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