Provider Demographics
NPI:1386762318
Name:BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY GROUP
Entity type:Organization
Organization Name:BLOOMINGTON ORAL & MAXILLOFACIAL SURGERY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:812-323-9700
Mailing Address - Street 1:637 S WALKER STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2154
Mailing Address - Country:US
Mailing Address - Phone:812-323-9700
Mailing Address - Fax:812-323-9701
Practice Address - Street 1:637 S WALKER STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2154
Practice Address - Country:US
Practice Address - Phone:812-323-9700
Practice Address - Fax:812-323-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ12010196A204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN228510Medicare ID - Type Unspecified