Healthcare Provider Details

I. General information

NPI: 1083613327
Provider Name (Legal Business Name): BLOOMINGTON NORMAL HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 FORT JESSE RD
NORMAL IL
61761-9370
US

IV. Provider business mailing address

2100 FORT JESSE RD
NORMAL IL
61761-9370
US

V. Phone/Fax

Practice location:
  • Phone: 309-834-4000
  • Fax: 309-834-4007
Mailing address:
  • Phone: 309-834-4000
  • Fax: 309-834-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7002512
License Number StateIL

VIII. Authorized Official

Name: DR. THOMAS B KULB
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 309-834-4000