Healthcare Provider Details

I. General information

NPI: 1225061393
Provider Name (Legal Business Name): BROMENN PHYSICIAN MANAGEMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE SUITE 4500
NORMAL IL
61761-3551
US

IV. Provider business mailing address

1302 FRANKLIN AVE SUITE 4500
NORMAL IL
61761-3551
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-1166
  • Fax: 309-862-0330
Mailing address:
  • Phone: 309-828-1166
  • Fax: 309-862-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM BROUWER
Title or Position: PRESIDENT, PHYSICIANS MGMNT CORP
Credential:
Phone: 309-268-2129