Healthcare Provider Details

I. General information

NPI: 1528003431
Provider Name (Legal Business Name): BROMENN HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVENUE SUITE 250
NORMAL IL
61761-3699
US

IV. Provider business mailing address

1300 FRANKLIN AVENUE SUITE 250
NORMAL IL
61761-3699
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-3642
  • Fax: 309-268-3649
Mailing address:
  • Phone: 309-268-3642
  • Fax: 309-268-3649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY A HAGENS
Title or Position: CHIEF OPERATING OFFICER AND VPMA
Credential: DMD
Phone: 309-268-2003