=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538435524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IU MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2012
-----------------------------------------------------
Last Update Date | 03/24/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 WISHARD BLVD 4TH FLOOR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46202-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-692-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8910 PURDUE RD STE 500
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46268-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-692-2323
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | CELIA SURFACE-BRUDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-871-8812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------