Provider Demographics
NPI:1982693743
Name:INDIANA UNIVERSITY
Entity type:Organization
Organization Name:INDIANA UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUMPHRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-855-4156
Mailing Address - Street 1:2631 EAST DISCOVERY PARKWAY
Mailing Address - Street 2:HEALTH SCIENCES BUILDING
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9059
Mailing Address - Country:US
Mailing Address - Phone:812-855-4156
Mailing Address - Fax:812-855-5531
Practice Address - Street 1:200 S JORDAN AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7002
Practice Address - Country:US
Practice Address - Phone:812-855-4156
Practice Address - Fax:812-855-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN231H00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100276980AMedicaid
IN100276980AMedicaid