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General NPI Number Information
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NPI Number | 1306816665
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON ENT PC
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 04/15/2008
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Provider Practice Location Address
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Address Line | 1791 W 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-5029
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Country | US
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Telephone | 812-335-1300
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Fax | 812-335-0300
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Provider Business Mailing Address
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Address Line | 1791 W 3RD ST
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City | BLOOMINGTON
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State | IN
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Zip | 47404-5029
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Country | US
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Telephone | 812-335-1300
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Fax | 812-335-0300
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Authorized Official
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Title or Position | OWNER
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Name | JESSE PHILLIPS
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Credential | MD
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Telephone | 812-335-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 01040385A
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License Number State | IN
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