Healthcare Provider Details

I. General information

NPI: 1750348843
Provider Name (Legal Business Name): LJUBOMIR M ILIC MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 812-676-4660
  • Fax: 812-676-4501
Mailing address:
  • Phone: 904-383-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME133258
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME133258
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number01084851A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: