Provider Demographics
NPI:1093990541
Name:ANESTHESIA CARE OF BLOOMINGTON PC
Entity Type:Organization
Organization Name:ANESTHESIA CARE OF BLOOMINGTON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-899-1412
Mailing Address - Street 1:PO BOX 10483
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0483
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:4011 S MONROE MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-8000
Practice Address - Country:US
Practice Address - Phone:812-825-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200889750AMedicaid
IN200889750AMedicaid