Healthcare Provider Details

I. General information

NPI: 1962489815
Provider Name (Legal Business Name): CARLE BROMENN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

IV. Provider business mailing address

1304 FRANKLIN AVE
NORMAL IL
61761-3558
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-5797
  • Fax: 309-268-5524
Mailing address:
  • Phone: 309-268-5797
  • Fax: 309-268-5524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054016773
License Number StateIL

VIII. Authorized Official

Name: ARON KLEIN
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 309-268-2410