Healthcare Provider Details

I. General information

NPI: 1144712563
Provider Name (Legal Business Name): TCOM SPECIALTY PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E EMPIRE ST STE B
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

PO BOX 775737
CHICAGO IL
60677-5737
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-6120
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: SARAH GARDNER
Title or Position: BUSINESS DIRECTOR
Credential:
Phone: 309-662-6120