Healthcare Provider Details

I. General information

NPI: 1871698761
Provider Name (Legal Business Name): MICHAEL WOODS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3170
  • Fax:
Mailing address:
  • Phone: 309-664-3170
  • Fax: 309-663-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036073539
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: