Healthcare Provider Details

I. General information

NPI: 1699870063
Provider Name (Legal Business Name): BROMENN HEALTHCARE OPEN MRI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

IV. Provider business mailing address

PO BOX 2850
BLOOMINGTON IL
61702-2850
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number1748518
License Number StateIL

VIII. Authorized Official

Name: MRS. KATHY DAVIS
Title or Position: VP/CIO/CORPORATE INTEGRITY OFFICER
Credential:
Phone: 309-268-2410