Healthcare Provider Details

I. General information

NPI: 1225476377
Provider Name (Legal Business Name): RACHEL EMILY IMMEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 04/20/2023
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 E EMPIRE ST STE A
BLOOMINGTON IL
61704-5402
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9801
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 42894
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number36149302
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036149302
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: