Healthcare Provider Details

I. General information

NPI: 1134308620
Provider Name (Legal Business Name): KENT S TAULBEE MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2418 E LINCOLN ST
BLOOMINGTON IL
61701-5915
US

IV. Provider business mailing address

2418 E LINCOLN ST
BLOOMINGTON IL
61701-5915
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6386
  • Fax: 309-662-7622
Mailing address:
  • Phone: 309-663-6386
  • Fax: 309-662-7622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: KENT S TAULBEE
Title or Position: CEO
Credential: MD
Phone: 309-663-6386