Healthcare Provider Details

I. General information

NPI: 1346333689
Provider Name (Legal Business Name): PAUL NORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 SAINT JOSEPH DR
BLOOMINGTON IL
61701-3506
US

IV. Provider business mailing address

2507 W WASHINGTON ST
BLOOMINGTON IL
61705-6344
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-5050
  • Fax: 309-663-3401
Mailing address:
  • Phone: 309-829-9975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number036-054760
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-054760
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036-054760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: