Provider Demographics
NPI:1780775163
Name:INDIANA UNIVERSITY HEALTH PROTON THERAPY CENTER, LLC
Entity type:Organization
Organization Name:INDIANA UNIVERSITY HEALTH PROTON THERAPY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KERSTIENS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:812-349-5028
Mailing Address - Street 1:2425 MILO B. SAMPSON LANE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-1398
Mailing Address - Country:US
Mailing Address - Phone:812-349-5074
Mailing Address - Fax:812-349-5046
Practice Address - Street 1:2425 MILO B. SAMPSON LANE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1398
Practice Address - Country:US
Practice Address - Phone:812-349-5074
Practice Address - Fax:812-349-5046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200442910AMedicaid
IN201140Medicare PIN