Healthcare Provider Details

I. General information

NPI: 1376571844
Provider Name (Legal Business Name): JOEL NILLES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIRGINIA & FRANKLIN STREETS
NORMAL IL
61761
US

IV. Provider business mailing address

213 WILLARD AVE
BLOOMINGTON IL
61701-5652
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-4321
  • Fax:
Mailing address:
  • Phone: 309-310-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036099319
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036-099319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: