Provider Demographics
NPI:1669609400
Name:BLOOMINGTON ORTHOPEDIC SPINE CLINIC LLC
Entity type:Organization
Organization Name:BLOOMINGTON ORTHOPEDIC SPINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAMMERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-333-1933
Mailing Address - Street 1:2201 W SUDBURY DR
Mailing Address - Street 2:STE C
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3812
Mailing Address - Country:US
Mailing Address - Phone:812-333-1933
Mailing Address - Fax:812-333-3991
Practice Address - Street 1:2201 W SUDBURY DR
Practice Address - Street 2:STE C
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3812
Practice Address - Country:US
Practice Address - Phone:812-333-1933
Practice Address - Fax:812-333-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065333A207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200949160AMedicaid
IN6307720001Medicare NSC
IN262850Medicare PIN