Healthcare Provider Details

I. General information

NPI: 1710213673
Provider Name (Legal Business Name): BROMENN PHYSICIAN MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

IV. Provider business mailing address

2406 E EMPIRE ST
BLOOMINGTON IL
61704-3630
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-9300
  • Fax:
Mailing address:
  • Phone: 309-663-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM BROUWER
Title or Position: PRESIDENT,PHYSICIAN MGMNT CORP
Credential:
Phone: 309-268-2129