Healthcare Provider Details

I. General information

NPI: 1639508567
Provider Name (Legal Business Name): THE BLEEDING AND CLOTTING DISORDERS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 07/30/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 W NORTHMOOR RD
PEORIA IL
61614-3542
US

IV. Provider business mailing address

427 W NORTHMOOR RD
PEORIA IL
61614-3542
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-5337
  • Fax: 309-693-3913
Mailing address:
  • Phone: 309-692-5337
  • Fax: 309-693-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number054-017718
License Number StateIL

VIII. Authorized Official

Name: MICHAEL TARANTINO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 309-692-5337