Healthcare Provider Details

I. General information

NPI: 1942592118
Provider Name (Legal Business Name): HEART OF ILLINOIS OBSTETRICS AND GYNECOLOGY, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR STE 2200
BLOOMINGTON IL
61701-7910
US

IV. Provider business mailing address

1505 EASTLAND DR STE 2200
BLOOMINGTON IL
61701-7910
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-3456
  • Fax: 309-454-6977
Mailing address:
  • Phone: 309-454-3456
  • Fax: 309-454-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036068939
License Number StateIL

VIII. Authorized Official

Name: MELISSA G GEORGAS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 309-838-6748