Healthcare Provider Details

I. General information

NPI: 1093100554
Provider Name (Legal Business Name): NICHOLAS FLORENCE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE
NORMAL IL
61761-3592
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036151532
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: