Healthcare Provider Details

I. General information

NPI: 1780870733
Provider Name (Legal Business Name): HEARTLAND EMERGENCY SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2007
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

2538 MOMENTUM PL
CHICAGO IL
60689-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-3311
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-078726
License Number StateIL

VIII. Authorized Official

Name: RICHARD DISSELKOEN CASTILLO
Title or Position: TREASURER
Credential: MD
Phone: 888-437-0911