Provider Demographics
NPI:1780637058
Name:INDIANA UNIVERSITY MEDICAL GENETICS SERVICE, INC.
Entity Type:Organization
Organization Name:INDIANA UNIVERSITY MEDICAL GENETICS SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAINLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:317-274-2966
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5181
Practice Address - Country:US
Practice Address - Phone:317-274-2966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207SC0300X, 207SG0201X, 207SG0203X, 207SM0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical CytogeneticsGroup - Single Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular GeneticsGroup - Single Specialty
No207SM0001XAllopathic & Osteopathic PhysiciansMedical GeneticsMolecular Genetic PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100460350Medicaid
IN100460350Medicaid