1184808404 NPI number — BROMENN HEALTHCARE, INC.

Table of content: (NPI 1184808404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184808404 NPI number — BROMENN HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROMENN HEALTHCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BROMENN PHYSICIANS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184808404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61702-2850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-268-5180
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 FRANKLIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAL
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-268-5180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CERMAK
Authorized Official First Name:
PENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
309-268-2185

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  0004812 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 827500 . This is a "MEDICARE PART B" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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