Healthcare Provider Details

I. General information

NPI: 1538230990
Provider Name (Legal Business Name): JOANNE M LAROW DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 GERIG DR STE 100
BLOOMINGTON IL
61704-6343
US

IV. Provider business mailing address

3302 GERIG DR STE 100
BLOOMINGTON IL
61704-6343
US

V. Phone/Fax

Practice location:
  • Phone: 309-533-7070
  • Fax: 855-710-6552
Mailing address:
  • Phone: 309-533-7070
  • Fax: 855-710-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036152444
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: