Healthcare Provider Details

I. General information

NPI: 1710810577
Provider Name (Legal Business Name): MEHRNOOSH EBADI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

V. Phone/Fax

Practice location:
  • Phone: 309-665-5996
  • Fax:
Mailing address:
  • Phone: 501-773-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.088029
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: