=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205821899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROSURGICAL CLINIC OF BLOOMINGTON INC P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 S COLLEGE AVE SUITE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-331-8168
-----------------------------------------------------
Fax | 812-331-1096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 S COLLEGE AVE SUITE A
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-331-8168
-----------------------------------------------------
Fax | 812-331-1096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARSHALL M. POOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 812-331-8168
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 01051484
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 01039391
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 01040149
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------