Healthcare Provider Details

I. General information

NPI: 1689166100
Provider Name (Legal Business Name): KOMAL MANOJ RAI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2100
US

IV. Provider business mailing address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2100
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3170
  • Fax: 309-664-3148
Mailing address:
  • Phone: 309-664-3170
  • Fax: 309-664-3148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036161312
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036161312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: