Provider Demographics
NPI:1063612257
Name:INDIANA STATE UNIVERSITY
Entity type:Organization
Organization Name:INDIANA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM PT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:812-237-9613
Mailing Address - Street 1:567 N 5TH ST.
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47809
Mailing Address - Country:US
Mailing Address - Phone:812-237-9613
Mailing Address - Fax:812-237-9612
Practice Address - Street 1:567 N 5TH ST.
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809
Practice Address - Country:US
Practice Address - Phone:812-237-9613
Practice Address - Fax:812-237-9612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009329A261QP2000X
IN05010420A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000528265OtherBLUECROSS & BLUE SHIELD
IN000000528265OtherANTHEM BLUE CROSS AND BLUE SHIELD
IN000000528265OtherANTHEM BLUE CROSS AND BLUE SHIELD