Healthcare Provider Details

I. General information

NPI: 1750567442
Provider Name (Legal Business Name): IRELAND GROVE CENTER FOR SURGERY LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 IRELAND GROVE ROAD
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

3801 IRELAND GROVE ROAD
BLOOMINGTON IL
61704
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-0101
  • Fax: 309-664-1010
Mailing address:
  • Phone: 309-664-0101
  • Fax: 309-664-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD KOLB
Title or Position: PRESIDENT
Credential: MD
Phone: 309-664-0101