Provider Demographics
NPI:1699718957
Name:INDIANA UNIVERSITY
Entity type:Organization
Organization Name:INDIANA UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MGR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-856-3624
Mailing Address - Street 1:803 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-3321
Mailing Address - Country:US
Mailing Address - Phone:812-855-1671
Mailing Address - Fax:812-855-5157
Practice Address - Street 1:803 N MONROE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3321
Practice Address - Country:US
Practice Address - Phone:812-855-1671
Practice Address - Fax:812-855-5157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000105528OtherANTHEM
IN100184630 AMedicaid
IN100184630 AMedicaid
IN0544790003Medicare NSC