Provider Demographics
NPI:1417968595
Name:BLOOMINGTON MEADOWS GP -
Entity Type:Organization
Organization Name:BLOOMINGTON MEADOWS GP -
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-331-8000
Mailing Address - Street 1:3600 N PROW RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-1616
Mailing Address - Country:US
Mailing Address - Phone:812-331-8000
Mailing Address - Fax:812-331-8985
Practice Address - Street 1:3600 N PROW RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-1616
Practice Address - Country:US
Practice Address - Phone:812-331-8000
Practice Address - Fax:812-331-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN278652298323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200457070AMedicaid