Healthcare Provider Details

I. General information

NPI: 1508889965
Provider Name (Legal Business Name): CENTRAL ILLINOIS ORTHOPEDIC SURGERY II LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR SUITE 220
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE 220
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-2278
  • Fax: 309-663-2956
Mailing address:
  • Phone: 309-662-2278
  • Fax: 309-663-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRETT L KELLER
Title or Position: OWNER
Credential: D.O.
Phone: 309-662-2278