Healthcare Provider Details

I. General information

NPI: 1033131479
Provider Name (Legal Business Name): JOHN A. POLLASTRINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE 1100
NORMAL IL
61761-0016
US

IV. Provider business mailing address

PO BOX 2451
BLOOMINGTON IL
61702-2451
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2727
  • Fax: 309-268-6513
Mailing address:
  • Phone: 309-268-2172
  • Fax: 309-268-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036073402
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: