Healthcare Provider Details

I. General information

NPI: 1730128315
Provider Name (Legal Business Name): MIDWEST CENTER FOR SLEEP MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 JUMER DR
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

1709 JUMER DR
BLOOMINGTON IL
61704-0914
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-9997
  • Fax: 309-663-9917
Mailing address:
  • Phone: 309-662-9997
  • Fax: 309-663-9917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License NumberNA
License Number StateIL

VIII. Authorized Official

Name: DR. LESLIE E MATHERS III
Title or Position: PRESIDENT BOARD OF DIRECTORS
Credential: M.D.
Phone: 309-664-3061