Provider Demographics
NPI:1003914920
Name:BLOOMINGTON DERMATOLOGY CLINIC
Entity Type:Organization
Organization Name:BLOOMINGTON DERMATOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILHELMUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-333-0398
Mailing Address - Street 1:2001 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-7890
Mailing Address - Country:US
Mailing Address - Phone:812-333-0398
Mailing Address - Fax:812-333-0698
Practice Address - Street 1:2001 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-7890
Practice Address - Country:US
Practice Address - Phone:812-333-0398
Practice Address - Fax:812-333-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042083A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000090314OtherANTHEM
$$$$$$$$$OtherSOCIAL SECURITY NUMBER
INB61252Medicare UPIN
IN=========OtherTAX ID