Provider Demographics
NPI:1275647083
Name:INDIANA BLOOD AND MARROW TRANSPLANTATION LLC
Entity Type:Organization
Organization Name:INDIANA BLOOD AND MARROW TRANSPLANTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR REV INTEGRITY
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-554-4548
Mailing Address - Street 1:PO BOX 781090
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1090
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-5500
Practice Address - Fax:317-528-7356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100131340Medicaid
IN100131340Medicaid