MEDICARE: MARTHA LOUISE UEBELHOER CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	28105421A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000249973	OTHER	IN	SIA ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003801218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA LOUISE UEBELHOER CRNA

Provider Business Mailing Address
First Line	:	PO BOX 5635
Second Line	:	ATTN: MARIA MITCHELL
City	:	BLOOMINGTON
State	:	IN
Zip	:	47407-5635
Country	:	US
Telephone Number	:	812-337-5003
Fax Number	:	812-337-5010

Provider Business Practice Location Address
First Line	:	2920 MCINTYRE DR
Second Line	:	SUITE 150
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-4221
Country	:	US
Telephone Number	:	812-333-7246
Fax Number	:	812-333-4471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	07/09/2007

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