Healthcare Provider Details

I. General information

NPI: 1386736023
Provider Name (Legal Business Name): JERRY ANTONINI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DRIVE SUITE 320
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE 320
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-2368
  • Fax: 309-662-9709
Mailing address:
  • Phone: 309-662-5361
  • Fax: 309-663-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: