Healthcare Provider Details

I. General information

NPI: 1306343603
Provider Name (Legal Business Name): KARAN RAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

2509 KEYSTONE RD
BLOOMINGTON IL
61704-8439
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3161
  • Fax: 309-664-3162
Mailing address:
  • Phone: 602-489-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number336.119768
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.072854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: